Zepbound is a medication that can be injected by prescription. It may help adults who are obese or overweight with weight-related medical issues to lose weight and maintain their weight loss.
But like with other medicines the price can be a problem for some people. That’s when insurance steps in. Many people ask, “Does Blue Cross Blue Shield cover ZepBound?”
In this article, we will discuss the specifics of whether the Blue Cross Blue Shield insurance policy covers the cost of the ZepBound.
We also discuss some other aspects like how you get Zepbound at an affordable price or provide information on other insurance companies that may offer coverage for ZepBound.
Closer Look At What is ZepBound?
ZepBound is an FDA-approved weight loss medication for certain adults who are obese or overweight with weight-related medical issues.
It helps in weight loss by mimicking the behavior of naturally occurring hormones in the gut that help regulate hunger and satiety.
Zepbound is a liquid solution that comes in prefilled injection pens. You simply inject the medicine under your skin once a week.
When injected under the skin, ZepBound slows down stomach emptying and prevents the liver from making too much sugar. This process reduces hunger and helps people to eat less.
Keep in mind that ZepBound is not a substitute for a healthy diet and regular exercise. It is typically prescribed in conjunction with a low-calorie diet and increased physical activity to help people lose weight and maintain weight loss.
What is Zepbound prescribed for?
ZepBound is mainly used to help adults who are very overweight or obese, and who have health problems because of their weight, to lose weight.
Prescribed for weight loss and long-term weight management in adults who meet either of the following criteria:
- Having a body mass index (BMI) of 30 or higher is considered obesity.
- Being overweight with a BMI of 27 or higher, combined with weight-related health issues like type 2 diabetes, high blood pressure, heart disease, high cholesterol, or obstructive sleep apnea.
Zepbound is recommended along with a healthy diet and exercise.
However, like all medications, ZepBound may have side effects, which can include:
- Diarrhea
- Constipation
- Headaches
- burping
- abdominal pain
- heartburn or indigestion (upset stomach)
- gas
- hair loss
Before starting ZepBound, it’s a good idea to talk to a healthcare professional about the risks and benefits of the medication.
With or Without Insurance How Much Does ZepBound Cost?
The cost of ZepBound medication can vary based on factors such as prescribed dosage, patient location, and insurance coverage.
According to GoodRx, the cost of a 28-day supply of Zepbound is $1,060, as stated in the official announcement by Lilly. Without insurance or any discounts, the annual expense for this medication can reach up to $13,800.
The cost is about 20% lower than the $1,350 list price of Novo Nordisk’s weight-loss medication called Wegovy, as stated by Eli Lilly the producer of Zepbound and Mounjaro.
However, the monthly cost is just only part of the story. According to a recent value analysis published in early 2023, it was found that the estimated cost of treating a 1% reduction in body weight with tirzepatide is $985, compared to $1,845 for semaglutide.
If your insurance covers ZepBound, your out-of-pocket cost can be greatly reduced. Note that the amount you pay and the coverage you receive may vary depending on your specific insurance plan.
How can I get Zepbound at an affordable price?
If you have commercial insurance that covers Zepbound, you might qualify to pay only $25 for a 1-month or 3-month prescription with the Zepbound Savings Card.
If your drug insurance doesn’t cover Zepbound, you could pay as little as $550* for a one-month supply.
Here is the card eligibility criteria:
- You have been given Zepbound as prescribed, following the instructions provided by the FDA for this product.
- You are enrolled in a commercial drug insurance plan.
- You are not currently enrolled in any healthcare program funded by the state, federal government, or any other government program. Examples include Medicaid, Medicare, Medicare Part D, Medicare Advantage, Medigap, DoD, VA, TRICARE/CHAMPUS, or state. prescription drug assistance programs.
- You are a resident of the United States or Puerto Rico.
- You are 18 years of age or older.
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Does Blue Cross Blue Shield Cover ZepBound?
Yes, the good news is that Blue Cross Blue Shield does provide coverage for ZepBound. But, how much of the cost is covered can differ a lot based on the plan and where the person lives.
Based on the BCBS Federal Employee Program website, ZepBound is a preferred brand name drug and is covered under their Preferred Brand Name Drug benefit. This means the medication is cheaper than non-preferred brand-name drugs.
However, it’s important to note that coverage may vary depending on your specific plan, so it’s best to speak with your insurance provider directly to get more details about your coverage.
You might also Like: Does Blue Cross Blue Shield Cover Wegovy For Weight Loss?
Does Blue Cross Blue Shield cover ZepBound for weight loss?
Yes, Blue Cross Blue Shield can cover ZepBound for weight loss treatments but there are specific conditions that must be met.
These may include providing proof that the treatment is necessary, following the prescribed dosage, and sticking to a diet and exercise plan recommended by the doctor.
Remember, coverage can be different for each plan and state laws so it’s important to go to your BCBS representative to understand what your specific plan covers.
You might also like: Does Blue Cross Blue Shield Cover Mounjaro For Weight Loss
What is eligibility for coverage?
To be eligible for coverage of ZepBound prescription by Blue Cross Blue Shield, individuals generally need to meet certain criteria:
- Being a resident of the U.S., Canada, or Puerto Rico.
- Having a body mass index (BMI) of 30 or higher is considered obesity, or having a BMI of 27 or higher combined with weight-related health issues.
- Working for a company that offers health insurance through BCBS.
- Your age must be between 18 to 64 years old.
- The person has tried and not succeeded in previous attempts to lose weight, including trying different diets and exercising.
- Make sure you don’t have any conditions like pregnancy or certain mental health issues that could prevent you from using ZepBound.
- Being prescribed ZepBound by a physician for the treatment of weight loss.
- Meeting any additional criteria set by the specific Blue Cross Blue Shield plan
Tips for getting coverage with Blue Cross Blue Shield
Here are some tips to ensure coverage for ZepBound with Blue Cross Blue Shield:
1. Check Your Plan Details: Make sure you understand the details of your insurance plan. Not all plans are the same, and coverage levels can differ. Verify the specifics of your plan and check if it covers weight loss treatments like ZepBound.
2. Pre-Authorization: Some insurance companies may need pre-authorization or approval before covering a new medication. Contact your insurance provider to check if ZepBound requires pre-authorization.
3. Document Your Medical History: Keep track of your past weight loss attempts: diets, exercise routines, and more. It’ll help demonstrate the need for your weight loss treatment.
4. Regular Check-ups: Regular check-ins with your provider not only track your progress but also validate the need for ongoing treatment.
5. Appeal Denied Claims: If your insurance claim for ZepBound is denied, you can appeal the decision. Collect all the important medical papers and letters from your doctor to help with your appeal.
What should you do if BCBS does not cover ZepBound?
If you find that ZepBound is not covered, you still have options:
- Speak to your provider about other weight-loss treatments that may be covered by BCBS.
- Research alternative insurance plans: If you’re able, consider switching to an insurance plan that covers ZepBound.
- Look for discounts or coupons on websites like GoodRx to lower the cost of prescription medications.
- Check if healthcare providers offer payment plans that allow you to pay for treatments over time without using insurance.
How to check your coverage?
Checking your coverage for ZepBound or any other prescription medication is a relatively straightforward process:
- Visit the Blue Cross Blue Shield website and create an account if you haven’t already.
- Log in to your account and go to the “My Coverage” section.
- Search for ZepBound or any other medication you’re curious about and check its coverage status.
- You can also contact BCBS directly through their customer service number or by messaging them through your online account for more specific coverage information.
- Ask if your policy covers the cost of a doctor’s visit to get a ZepBound prescription.
- Ask about any requirements or criteria to qualify for coverage.
What other insurance covers ZepBound?
Several other insurance providers besides Blue Cross Blue Shield offer coverage for ZepBound.
Some prescription medication plans don’t cover expensive weight-loss medications, but there are exceptions with prior authorization. ZepBound might be included in plan formularies in the future.
After FDA approval for weight loss, Eli Lilly has shared information on how Zepbound might be covered by different insurance plans. These include:
- Medicaid: ZepBound is covered by Medicaid in most states. Please utilize the Eli Lilly directory located at the bottom of this page to access the preferred medication list for your state’s Medicaid program. If your state doesn’t cover Zepbound in the Medicaid program, you can talk to your provider about submitting an appeal.
- Medicare: Medicare does not cover weight-loss medications like ZepBound. However, certain retiree health insurance plans might include coverage for them.
- U.S. Department of Veterans Affairs (VA): ZepBound may cover by VA health coverage. However, you should check with your local VA office for more information.
- TRICARE: The TRICARE pharmacy benefit covers 100% of the cost for FDA-approved weight-loss medications like Zepbound. But your healthcare provider might have to request a coverage review, which is similar to getting prior authorization.
- Private insurance: Private insurance plans may cover ZepBound, but It depends on your insurance plan and if they approve it beforehand. It’s a good idea to contact your insurance provider for more details on what they cover.
Most Medicaid programs don’t cover weight-loss medications. However, as of July 1, 2023, at least one state in the US covers them in 16 states. For complete list visit GoodRx
Conclusion
To get coverage for ZepBound, like any prescription medication, you need to understand your insurance plan, keep detailed medical records, and be proactive in appealing denied claims.
If BCBS does not cover ZepBound, you have multiple options like seeking alternative treatments, exploring other insurance plans, or using discounts and out-of-pocket payment plans. But make sure to check your coverage details with your insurance provider and explore all possible avenues to get the necessary treatment for weight loss.
FAQ
Does Blue Cross Blue Shield cover Zepbound in California?
Yes, Blue Cross Blue Shield in California covers ZepBound, unless your employer excludes weight loss medications from your coverage plan. It’s key to verify the specifics of your insurance policy, as plan details can vary significantly. If weight loss medications are included in your plan, you should be eligible for coverage for ZepBound.
Does Blue Cross Blue Shield cover Zepbound in Texas?
Yes, Blue Cross Blue Shield does cover ZepBound in Texas. However, the extent of the coverage depends on the specifics of your insurance plan. We recommend first talk to your insurance provider directly for more detailed information about the coverage of weight loss medications.
Does Medicare pay for Zepbound?
No, Medicare does not usually cover the cost of weight-loss medications like ZepBound. However, some Medicare Advantage plans or retiree health insurance plans may provide coverage. It is important to check directly with your insurance provider for the most accurate information.
