When it comes to managing healthcare costs, understanding your insurance coverage is crucial. If you’re considering Zepbound as a treatment option, it’s important to know whether United Healthcare (UHC) covers this medication. In this comprehensive guide, we’ll explore the coverage options for Zepbound, a weight loss medication, under various UHC plans, including Medicare, Medicaid, and individual plans.
Understanding Zepbound
Brand name Zepbound is a new medication manufactured by Eli Lilly that has gained attention for its potential as a weight loss drug. It is a cutting-edge drug that has shown promising results in body weight reduction in clinical trials. The drug joins a list of six other similar prescription drugs that are FDA-approved (Food and Drug Administration). Like Novo Nordisk’s Ozempic and Wegovy, both containing the active ingredient semaglutide, Zepbound targets specific mechanisms in the body to promote weight loss and contains the active ingredient tirzepatide.
Indications for Use
Zepbound is indicated for chronic weight management in adult patients with obesity with a BMI (body mass index) of 30+, or who are overweight with a BMI of 27+ with weight-related medical health conditions. Weight-related conditions may include high blood pressure (hypertension), type 2 diabetes, obstructive sleep apnea, cardiovascular disease or high cholesterol. It is typically prescribed in conjunction with a low-calorie diet and increased physical activity to help people lose weight and maintain weight loss.
How Zepbound Works
The active ingredient in Zepbound is tirzepatide, a GIP and GLP-1 receptor agonist. Zepbound works by acting like GLP-1 and GIP, 2 hormones released in your gut that are involved in the regulation of blood sugar and appetite. GLP-1 and GIP target areas in your brain to help decrease appetite and slow down digestion to help you feel full faster and longer. This can help you eat less and is what makes Zepbound an effective weight loss medication.
Navigating United Healthcare Coverage for Zepbound
Determining whether United Healthcare covers Zepbound requires a thorough understanding of your specific plan and its Prescription Drug List. By accessing your plan’s PDL and reviewing the tier and cost-sharing details for Zepbound, you can make informed decisions about your healthcare.
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Prescription Drug Lists (PDLs) Explained
To determine whether Zepbound is covered by UHC, we need to familiarize ourselves with Prescription Drug Lists (PDLs). Also known as formularies, PDLs are lists of medications categorized into different cost levels or tiers. These tiers determine the amount you will pay for a specific medication based on your insurance plan.
Health Insurance Marketplace Plans
If you have a health plan through the Health Insurance Marketplace, also known as a State Exchange plan, it’s essential to check the PDL specific to your plan to determine the coverage and cost of Zepbound. The PDL will indicate the tier in which Zepbound falls and the corresponding cost-sharing details.
Small and Large Group Plans
For individuals covered under UHC’s Small and Large Group plans, the PDL will determine the coverage and cost-sharing for Zepbound. It’s important to note that the PDL may vary depending on the specific plan offered by your employer. To access your plan’s PDL, sign in to your UHC account and navigate to the pharmacy benefits section.
Medicare Coverage
If you’re enrolled in a Medicare plan through UHC, you may be wondering whether Zepbound is covered. Medicare plans typically have their own PDLs, which outline the coverage and cost-sharing for prescription medications.
Medicaid Coverage
Medicaid plans vary by state, so coverage for Zepbound will depend on the specific Medicaid plan you’re enrolled in. Navigating prescription drug coverage can be complex, but UHC provides additional resources to help you understand your coverage options.
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Factors Influencing Zepbound Coverage
Several factors can influence whether United Healthcare covers Zepbound for weight loss.
Type of Insurance Plan
Plans such as PPOs (Preferred Provider Organizations) and HMOs (Health Maintenance Organizations) have different rules and requirements, which can affect your coverage. Depending on your plan, certain medications may not be covered or can require prior authorization (sometimes referred to as precertification) if similar alternative medications are available at a lower cost.
State of Residence
There may be different benefits based on the state you live in.
Prior Authorization
“From my clinical experience, most health insurance plans require pre-authorization to cover Zepbound,” said Dr. Makhija. To receive approval under prior authorization, patients will need to meet explicit requirements outlined in their specific health benefits plan. Requirements for coverage can include a certain body mass index (BMI) threshold, documentation of previous healthy lifestyle changes and weight loss efforts, and weight-related comorbidities. Weight-related comorbidities refer to health conditions caused by obesity, like dyslipidemia, hypertension, Type 2 diabetes, or sleep apnea. A healthcare professional would then need to submit these details to United Healthcare to further determine if you’re eligible.
Coverage Duration
If United Healthcare does cover initial weight loss treatment with Zepbound, typically, it is only for the first six months.
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Step Therapy
“In many cases, even when patients meet all criteria-BMI, FDA-approved indication, and prior weight loss efforts-insurance companies may still require them to try other weight loss medications (typically oral tablets) before approving Zepbound,” explained Dr.
What If Zepbound Isn't Covered?
If your United Healthcare plan doesn’t cover Zepbound, there are still ways to save money on the drug.
SingleCare Discount Savings Cards
A SingleCare prescription drug discount card can save you hundreds of dollars on Zepbound.
Shapely as an In-Network Provider
Shapely is proud to be an in-network provider with UnitedHealthcare, making our evidence-based weight loss care more accessible and affordable for millions of Americans. Through this partnership, eligible UnitedHealthcare PPO members can receive personalized medical care, lifestyle coaching, and expert weight loss support-all covered by their insurance plan.
Affordable Alternatives Through Compounding Pharmacies
If your plan does not cover weight loss medications, Shapely offers affordable alternatives through our compounding pharmacy partners at a fraction of the cost of brand-name options.
Additional Considerations
Cost of Zepbound
If you don’t have insurance coverage for Zepbound, like all GIP/GLP-1 or GLP-1 drugs, it can cost a pretty penny. The exact price of Zepbound will vary depending on where you live and which pharmacy you use, but on average, the cost of Zepbound for 28 days can be in the ballpark of $1,500. This covers the cost of four single-dose injectable pens.
Out-of-Pocket Costs
Even if Zepbound is covered by United Healthcare services, it’s important to note that patients can still expect to pay some out-of-pocket costs (which may or may not be added to your deductible, depending on your plan). A copay, or co-payment, is what the customer is left to pay after the insurance coverage has been deducted. According to United Healthcare, the average copay cost for prescription drugs is between $15 to $60.
Importance of a Comprehensive Approach
“GLP-1s shouldn’t be looked at as a single-point solution. Individuals who take these drugs are more successful at achieving and maintaining their weight loss goals when they are part of a comprehensive lifestyle management program. - Dr.
Weight-loss programs that take a whole-person approach - including pharmaceutical, clinical and behavioral support - can be more effective at treating all aspects of a person’s health.
Potential Side Effects and Drug Interactions
When Zepbound is taken with other prescription drugs, over-the-counter medications, vitamins, herbal products, and supplements, it may change how they work or increase the risk of side effects. Oral birth control pills may not work as well if you take Zepbound. Use another type of birth control for 4 weeks after starting and after each dose increase.
How to Use Zepbound
Zepbound is injected subcutaneously (under the skin) once a week in the stomach, thigh, or back of the upper arm. The injection day can be changed with at least 3 days between doses. If you miss a dose, inject within 4 days. If more than 4 days have passed, skip the missed dose and take the next one as scheduled. Do not take 2 doses within 3 days. Rotate injection sites with each injection within the same area of the body.