Understanding healthcare and insurance can be confusing, like finding your way through a maze. It’s especially tricky when you figure out what your insurance covers for certain medicines.
This is the case for new treatments like Zepbound, which bring hope and a better quality of life for people with type 2 diabetes.
This article explains Aetna’s 2024 coverage for Zepbound in simple terms. We’ll talk about whether this insurance company covers Zepbound and, if so, how you can claim benefits. So, if you are an Aetna policyholder and considering Zepbound as a treatment option, keep reading to find out more.
Understanding Zepbound
Zepbound, also known as trizepatide, is an ingredient that is already approved under the brand name Mounjaro for reducing blood sugar in adults with type 2 diabetes. It has received approval from the FDA not only regulates blood sugar but also reduces the chances of heart disease and stroke.
The medication Dr. Saunders prescribes is a game-changer, known as a dual agonist. Because it targets two key hormones—glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1)—it reduces hunger feelings and curbs your food cravings.
Exactly How Does It works?
Zepbound works by mimicking the effects of natural hormones in the body, specifically glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1).
These hormones play crucial roles in regulating blood sugar levels. Upon ingestion, Zepbound activates receptors for these hormones, leading to enhanced insulin production when blood sugar is high.
Plus, it also slows down the emptying of the stomach, promoting a feeling of fullness and reducing overall appetite. This duo can really help handle blood sugar levels better and might even help with shedding some pounds, which is very useful for people with type 2 diabetes dealing with obesity.
How much does Zepbound cost with or without insurance?
The cost of Zepbound, like most prescription medications, can vary widely based on several factors such as your insurance plan, the pharmacy you choose, and any available manufacturer discounts or copay cards.
Usually, patients may pay around $1,059.87 per month for Zepbound, but costs can be lower with insurance or discount cards. If no insurance or manufacturer discounts are available, the annual cost of Zepbound can be $13,800.
For those without insurance, the retail price of Zepbound could be quite high, often reaching several hundred dollars per month. However, Eli Lilly, the manufacturer of Zepbound, offers a savings card that may significantly reduce this cost for eligible patients.
Does Aetna cover Zepbound?
Zepbound isn’t currently available everywhere as it’s not on Aetna’s 2024 drug list. Aetna, along with many insurance providers, takes a detailed approach to covering new medications like Zepbound.
In some places, Aetna includes Zepbound in the list of medicines it covers, especially if you buy it from specific pharmacies that Aetna prefers. This means people with Aetna in those areas can pay less when they get their prescriptions from these pharmacies.
But in other areas or at pharmacies Aetna doesn’t prefer, you might find that Zepbound isn’t covered or is only partly covered, so you’d have to pay more out of your own pocket.
I saw a Reddit user mention they started Zepbound with Aetna on Thursday. They had to get pre-authorization from the doctor, but it got approved, and they only paid $25 without the coupon. They’re in PA and use Coatesville Community Pharmacy. Interestingly, Rite Aid and CVS didn’t have it. The pharmacist even advised them to refill it sooner because it might be tough to get it next month, even though it’s currently in stock at their supplier.
Note: there is not a solid yes or no answer to whether Aetna covers Zepbound in its coverage at this time. Unfortunately, it varies based on your location and pharmacy preference.
Also Read: Does United Healthcare Cover Zepbound 2024?
The cost of Zepbound under Aetna plans
The cost of Zepbound under Aetna’s insurance plans can vary significantly based on the patient’s specific policy and the need for pre-authorization.
Generally, with pre-approval and buying Zepbound at a pharmacy preferred by Aetna, patients may pay way less. Some people paid only $25 for their prescription with the right approvals and meeting the conditions.
However, without insurance coverage or in areas where Zepbound is not on the formulary, patients could face the full retail price unless they can utilize manufacturer discounts or savings programs.
It is better for patients to consult with their providers and Aetna representatives to understand their coverage details and the steps required to potentially minimize their expenses.
Also Read: Does Blue Cross Blue Shield Cover ZepBound?
What are the eligibility criteria for Zepbound coverage with Aetna?
Note from Atena: Some Aetna plans do not cover services or supplies for treating obesity or for diet and weight control. This means claims for weight loss medications and physician supervision of weight loss programs may be denied. Check your benefit plan details for more information.
- Aetna allows up to 26 visits per year for weight reduction counseling for adults with obesity (BMI 30 or higher). The number of visits for obese children is decided by the member’s doctor.
Medical Assessment of Overweight or Obese Individuals
- Comprehensive history and physical examination
- Complete blood count
- Electrocardiogram (EKG) – adult
- Dexamethasone suppression test and 24-hour urinary free cortisol measurements are conducted when symptoms indicate Cushing’s syndrome.
Very Low Calorie Diets (VLCD)
For overweight people following a very low-calorie diet (less than 799 Kcal/day) like Optifast or Medifast, certain services are needed for up to 16 weeks after starting the diet:
- Heart check after losing 50 lbs;
- Cholesterol check at the start and end of the diet;
- Blood tests weekly during the fast weight loss phase, then every 2 weeks up to 16 weeks.
For more detail visit there Policy of Weight Reduction Programs
Related: Does Cigna Healthcare Cover Zepbound?
CHECKING YOUR ZEPBOUND COVERAGE
To check your Zepbound coverage under Aetna or any other insurance plan, follow these steps:
1. Verify with Your Insurance Provider: The most important first step is to call your insurance company. Look for their number on your insurance card or website. Make sure to have your policy number ready when you call.
2. Consult Your Healthcare Provider: Your doctor can check if Zepbound is included in your insurance. They know about pre-approvals and can give advice from helping other patients.
3. Utilize Online Resources: Many insurance companies, including Aetna, offer online portals where members can log in to check their coverage for specific medications. You’ll usually need to register or log in to access this feature.
4. Check the Eli Lilly Savings Program: Since Eli Lilly manufactures Zepbound, visiting their official website to explore available savings or discount programs is a valuable step. These programs can provide significant assistance, especially if your insurance has limited or no coverage for Zepbound.
5. Review Your Insurance Plan’s Formulary: Insurance plans have lists of covered medications (called formularies) to show if Zepbound is covered. Remember, these lists change, so always check the most recent one or ask your insurance provider directly.
Remember, insurance for medications can be complex and varies widely based on your plans, locations, and specific medical needs. Taking these steps will help you better understand your coverage and reduce out-of-pocket costs for Zepbound.
How to get insurance coverage for Zepbound?
Getting insurance for Zepbound needs planning and teamwork between healthcare providers, insurance companies, and maybe the drug maker. Here are the main steps to follow:
1. Consult Your Doctor: Discuss Zepbound with your healthcare provider to see if it’s a suitable option for your condition. They can initiate the pre-authorization process if necessary.
2. Pre-Authorization: Many insurance plans require pre-authorization for specific medications. This involves your doctor submitting information to your insurance company to justify the need for Zepbound.
3. Insurance Verification: Contact your insurance provider directly to confirm if Zepbound is covered under your plan and to understand the specifics of the coverage.
4. Manufacturer Support Programs: Explore any support or discount programs offered by Eli Lilly, the manufacturer of Zepbound. These can provide savings for patients without complete insurance coverage.
5. Appeal Denials: If your initial request for coverage is denied, you have the right to appeal the decision. Work with your healthcare provider to gather the necessary documentation and evidence supporting the need for Zepbound.
Factors influencing coverage of Zepbound with Aetna
The following factors may play a role in determining the coverage of Zepbound with Aetna:
- Policy Specifics: Every Aetna plan has different rules that decide what Zepbound is covered, so it’s important for members to carefully read their policy papers.
- Formulary Inclusion: When Zepbound is on the list of approved medications that Aetna covers, it affects how much is paid for it. If a medication isn’t on this list, it might not be covered or could cost more.
- Treatment History: Aetna may evaluate an individual’s previous weight loss efforts, including diet, exercise, and other medications, before approving coverage for Zepbound.
- Why Zepbound is Needed: Doctors must agree that Zepbound is really needed. They need to write down why the patient needs it and how it will help.
- Pre-authorization Requirements: Some Aetna plans mandate pre-authorization for Zepbound which means the healthcare provider must obtain approval from Aetna before the medication is covered.
Conclusion
Understanding how to get insurance to pay for medicines like Zepbound can be hard, but knowing what to do can make it easier. If you collaborate with your healthcare team to see if the drug company can help and ensure you follow insurance guidelines, it can help you access the treatment you require. Keep yourself informed about your insurance plan and speak up for your health to secure the medications that could have a significant impact.
FAQ
Does Aetna cover Zepbound for weight loss?
Coverage for Zepbound under Aetna insurance plans for weight loss varies by policy. It’s crucial to consult with your insurance provider and review your specific plan details to understand coverage options and any associated requirements like pre-authorization or treatment history documentation.
Can I get coverage for Zepbound if it’s not included in my Aetna plan’s formulary?
Yes, you may still get coverage through an appeals process or by applying for a formulary exception. This process requires your healthcare provider to submit additional documentation on why Zepbound is necessary for your treatment.
How long does the pre-authorization process for Zepbound typically take?
The duration of the pre-authorization process can vary, but generally, it takes from a few days up to a couple of weeks. It’s important to start this process early and stay in connected with your healthcare provider and insurance company.
Are there any alternative medications to Zepbound that might be easier to get coverage for?
Yes, there are alternative medications to Zepbound that your healthcare provider might consider if getting coverage proves difficult. These alternatives include other FDA-approved weight loss medications like Saxenda, Contrave, and Qsymia. However, first consult with your healthcare provider before making any changes to your treatment plan.
Does Aetna cover weight loss injections?
Aetna’s coverage for weight loss meds, like Zepbound, depends mostly on your health plan details, if the drug is on your plan, and if it’s medically necessary. Many Aetna plans typically don’t cover weight reduction meds under pharmacy or health benefits. However, some employers’ Aetna plans may offer weight reduction meds coverage. It’s best to check with your insurance provider directly for more information on specific coverage details.