Understanding health insurance benefits and coverage can be like solving a tricky puzzle, especially when it comes to new-release medications like Zepbound.
With so many different insurance providers and plans available, it can be confusing to determine what is and isn’t covered. One common question asked by those interested in trying Zepbound is whether or not United Healthcare covers this new medication.
To answer this question, we first need to understand what type of insurance coverage United Healthcare provides.
This article aims to unravel the complexities of insurance policies, providing clarity and insight into United Healthcare’s stance on Zepbound coverage. We examine the policy details, what’s not covered, and how to qualify. Our goal is to help patients understand their healthcare choices better.
What Exactly Is Zepbound?
Zepbound (trizepatide) is an injectable prescription medication approved by the U.S. Food and Drug Administration (FDA) on November 8, 2023. Right now, there isn’t a generic version of the drug. It is prescribed for adults with type 2 diabetes to manage blood sugar levels and lower the chances of heart disease and stroke.
Zepbound is most effective when you eat less and move more. It’s a liquid in ready-to-use injection pens. Instead of insulin or pills, you inject it under your skin just once a week.
How Zepbound Work With Healthcare?
Zepbound operates by mimicking the effects of GLP-1 (glucagon-like peptide-1). This hormone helps control blood sugar. When you eat, your body naturally releases GLP-1, which then tells your body to release insulin.
Insulin helps glucose obtained from food to be absorbed by the body’s cells for energy, thereby reducing blood sugar levels. Plus, GLP-1 suppresses the release of glucagon, a hormone that increases blood sugar levels, after meals.
This dual mechanism of increasing insulin while decreasing glucagon effectively lowers blood sugar levels. Trizepatide in Zepbound works like natural GLP-1 but lasts longer, so it only needs to be taken once a week instead of more often like the body’s hormone.
Zepbound Cost With Or Without Insurance
The cost of Zepbound can vary significantly based on several factors including insurance coverage, the specific insurance plan, and pharmacy location.
Zepbound goes for about $1,059.87 per month, but you might pay less with insurance or discount cards. Without insurance or manufacturer discounts, the cost of Zepbound can 13800$ per year.
However, you may be able to pay less for Zepbound if you have insurance coverage or if you qualify for patient assistance programs. For example, if your plan covers it, the cost could be as low as $25 per prescription until December 31, 2024.
Does United Healthcare cover Zepbound?
Yes, United Healthcare has officially confirmed on their website that they will include Zepbound in their coverage starting March 1, 2024. It means they can get this new medication more easily, which could change their lives for the better.
It’s available in US pharmacies and may cost you up to $550 per month with medication coupons. However, insurance coverage can significantly reduce the out-of-pocket cost for eligible patients. It’s
United Healthcare deciding to pay for Zepbound shows they want their members to get new diabetes treatments. From March, eligible United Healthcare members can use their plans to pay for Zepbound. It will be cheaper and easier to get for those who need this once-a-week shot.
This news gives hope to many people. It shows progress toward better healthcare for those with ongoing health problems.
You can check out this update in the United Healthcare documents for more confirmation.
Also Read: Does Blue Cross Blue Shield Cover ZepBound?
What is the cost of Zepbound on United Healthcare Plans?
The cost of Zepbound under United Healthcare plans can vary significantly, depending on the specific insurance policy and the details within it, like deductibles, co-pays, and out-of-pocket maximums.
For members covered by United Healthcare, starting March 1, 2024, Zepbound could be accessible at a more affordable rate, potentially as low as $25 per prescription, as mentioned earlier, until December 31, 2024.
This special pricing is part of an effort to make essential diabetes medications more accessible to those who need them.
We suggest you directly consult with United Healthcare or visit their online portal for the most accurate and up-to-date information regarding Zepbound’s coverage.
This will include specific details on eligibility, necessary prerequisites for coverage (like prior authorization), and the actual costs based on their plan.
Eligibility criteria for Zepbound
To be eligible for Zepbound coverage under United Healthcare, members must meet certain criteria, which may include but are not limited to:
1. BMI Requirement: Patients should have a Body Mass Index (BMI) of 27 kg/m2 or higher if they are overweight and have at least one weight-related health condition like hypertension, Type 2 diabetes, or high cholesterol. For those without a weight-related condition, a BMI of 30 kg/m2 or higher is usually required.
2. Type 2 Diabetes Diagnosis: Zepbound is specifically approved for adults with Type 2 diabetes. Patients need a formal diagnosis to qualify.
3. Previous Medication Attempts: Patients might need to have tried other diabetes medications first without satisfactory control of their blood sugar levels.
4. Regular Monitoring: Eligible patients must be willing to undergo regular monitoring of their blood sugar levels, as advised by their healthcare provider. This is to ensure the effectiveness of the treatment and adjust doses as necessary.
Zepbound may also be eligible for adults who are overweight with other health conditions like:
- Dyslipidemia (high levels of cholesterol in the blood)
- Cardiovascular disease
- Hypertension
- Type 2 diabetes
- Obstructive sleep apnea
If you have any of these conditions, it’s best to consult with your doctor to see if Zepbound is a suitable option for you.
Also Read: Does Aetna Cover Zepbound 2024?
Exactly How To Check The Zepbound Coverage?
Checking your Zepbound coverage with United Healthcare is pretty simple. You’ll get all the details about your benefits and how they work for this medication. Here’s how to find out your coverage details:
1. Log into your Member Portal: Access your United Healthcare member account through their official website or mobile app. This is your primary gateway to all your plan information.
2. Use the Coverage & Benefits Feature: Look for a section labeled “Coverage & Benefits” or a similar term. Here, you can review the specifics of what your plan covers, including prescriptions like Zepbound.
3. Contact Customer Service: If you can’t find what you need online or want to talk to someone, use the number on your insurance card. Be ready with specific questions about Zepbound coverage.
4. Ask about Prior Authorization: Some medications require prior authorization. Enquire if this is the case for Zepbound under your plan and what steps you need to take to complete this process, if necessary.
5. Inquire about Out-of-Pocket Costs: Understand your deductible, co-pay, and out-of-pocket maximums as they relate to prescription medications. Ask for an estimate of what your personal cost for Zepbound would be.
6. Pharmacy Information: Confirm with United Healthcare which pharmacies in your area are in-network. Using an in-network pharmacy could decrease your costs.
By following these steps, you’ll gain a complete understanding of your coverage for Zepbound with United Healthcare, allowing you to make informed decisions about your healthcare and financial planning.
Understanding To Get Insurance Coverage For Zepbound
To ensure insurance for Zepbound, follow these steps to align your healthcare provider and insurance company on your treatment plan.
1. Doctor’s Prescription: Your healthcare provider must prescribe Zepbound for you, noting its necessity for your health condition.
2. Verification of Benefits: Your healthcare provider or you may need to verify with your insurance company that Zepbound is covered under your plan. This might involve submitting a form or making a call to your insurance’s customer service.
3. Prior Authorization: Most of the time insurance companies require prior authorization for certain prescriptions. This means your doctor will need to submit a request to your insurance company proving that Zepbound is medically necessary for your condition.
4. Submit Any Required Documentation: If your insurance company requires further documentation, like medical records or a letter of medical necessity, ensure these are submitted promptly.
5. Appeal if Necessary: If they say no at first, you can ask again. Your doctor might need to explain more to the insurance company.
6. Patient Assistance Programs: If you’re having money problems or if your insurance doesn’t pay for Zepbound, check out programs that can help. The company or other groups may give you the medicine for less money or even for free if you qualify.
7. Regularly Review Your Coverage: Insurance policies and coverage can change. Regularly review your plan and stay informed about any changes to your medication coverage options.
Each insurance plan is different. It’s important to talk with your doctor and insurance company to understand exactly what you need to do.
Factors that determine the coverage
The coverage of Zepbound with United Healthcare, like other medicines, depends on different things that can be different for each person’s policy. These things include, but are not limited to:
1. Type of Insurance Plan: Plans like HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations) have different rules and networks, which can affect medication coverage.
2. Formulary Status: Whether Zepbound is listed on the United Healthcare formulary, which is a list of medications the plan covers, and at what tier. Medications on higher tiers may have higher out-of-pocket costs.
3. Clinical Guidelines: Coverage can be affected by clinical guidelines that outline the use of the drug, including the specific conditions it must be used for and any step therapy protocols.
4. State Regulations: State laws and regulations can influence prescription drug coverage, including mandated benefits that affect what insurance companies must cover.
Conclusion
Understanding your insurance for medicines like Zepbound might seem complex, but knowing your policy and being proactive can help make things simpler. Follow these steps to manage your health better: check coverage, talk to your healthcare provider, and keep in touch with your insurance.
Stay informed and take action when dealing with authorizations, patient programs, or coverage changes. By being proactive, you can get the support you need for Zepbound and a smoother healthcare journey.
FAQ
Can I get Zepbound if my insurance plan is not listed as covering it in the formulary?
Yes, you may still be able to get Zepbound even if it’s not listed in your insurance plan’s formulary. You might need a prior authorization from your provider, or you can appeal the decision with your insurance company.
What steps should I take if my prior authorization for Zepbound is denied?
If your prior authorization is denied, you can file an appeal with your insurance company. Your doctor may need to provide additional information to justify the medical necessity of Zepbound for your condition. Don’t hesitate to inquire about the appeal process and any specific documentation required.
Are there any alternatives to Zepbound if I can’t afford it or it’s not covered by my insurance?
If Zepbound is not covered by your insurance, or if you find it unaffordable, it’s important to consult with your healthcare provider about possible alternatives. There may be other medications that can treat your condition effectively and are covered by your insurance plan.
