Is Tirzepatide Covered by Insurance? How to Maximize Your Coverage for Mounjaro and Zepbound

Tirzepatide has gained widespread attention for its effectiveness in managing Type 2 diabetes and promoting weight loss. Sold under the brand names Mounjaro and Zepbound, this dual GLP-1 and GIP receptor agonist has been shown to outperform many existing treatments. However, given its high cost, many patients ask SuperDial: Is Tirzepatide covered by insurance?

The answer is too complicated to give in one sentence. In this guide, we’ll explore whether insurance covers Mounjaro and Zepbound, how to check your benefits, and ways to reduce your out-of-pocket costs.

What Is Tirzepatide and How Does It Work?

Tirzepatide is an injectable medication that mimics two natural gut hormones—GLP-1 and GIP—to regulate blood sugar, improve insulin sensitivity, and suppress appetite. This dual mechanism makes it particularly effective in both diabetes management and weight reduction. It is prescribed under two different brand names:

• Mounjaro – FDA-approved for Type 2 diabetes treatment, prescribed to improve glycemic control in adults with Type 2 diabetes when combined with diet and exercise.
• Zepbound – FDA-approved for weight management in adults with obesity (BMI ≥30) or overweight individuals (BMI ≥27) with at least one weight-related condition such as hypertension, sleep apnea, or high cholesterol.

Tirzepatide has demonstrated superior results compared to other GLP-1 medications such as Semaglutide (Ozempic, Wegovy). Clinical trials indicate that patients using Tirzepatide experience significant reductions in both blood sugar levels and body weight, making it a preferred choice for many healthcare providers.

Because of its effectiveness, there is growing interest in whether insurance plans cover the high costs associated with Tirzepatide treatment.

Does Insurance Cover Tirzepatide?

Insurance coverage for Tirzepatide depends on several factors, including the specific diagnosis, insurance provider, and plan details. The following sections break down coverage possibilities for both Mounjaro and Zepbound.

1. Insurance Coverage for Mounjaro (Type 2 Diabetes Treatment)

• Mounjaro is more likely to be covered by insurance because diabetes medications are typically classified as medically necessary.
• Private insurance plans (Aetna, Blue Cross Blue Shield, Cigna, etc.) often cover Mounjaro but may require a prior authorization to prove necessity.
• Medicare Part D & Medicaid generally cover Mounjaro, but patients may face coverage restrictions, such as formulary placement and step therapy requirements.
• Step therapy policies require patients to try and fail other diabetes medications, such as Metformin or insulin, before being approved for Mounjaro.
• Patients may still face copayments or coinsurance, depending on their specific plan and coverage tier.

2. Insurance Coverage for Zepbound (Weight Loss Treatment)

• Zepbound faces more restrictive insurance coverage since many insurers classify weight-loss drugs as elective rather than medically necessary.
• Some private insurance companies cover Zepbound under their obesity management plans, but policies vary widely between providers.
• Medicare does NOT cover weight-loss medications, including Zepbound, due to federal regulations that exclude obesity drugs from coverage.
• Medicaid coverage varies by state, with some states including obesity medications in their formulary while others do not.
• Patients seeking coverage for Zepbound may need to provide medical documentation proving weight-related health conditions, such as Type 2 diabetes, high blood pressure, or sleep apnea, to justify medical necessity.

How to Check If Your Insurance Covers Tirzepatide

To determine whether your insurance covers Mounjaro or Zepbound, follow these steps:

Step 1: Check Your Insurance Formulary

Most insurers maintain an online formulary list where you can look up covered drugs. Search for Mounjaro or Zepbound and pay attention to:

• Whether the medication is covered under your plan.
• The pricing tier (higher tiers typically have higher out-of-pocket costs).
• Whether a prior authorization is required.
• Any step therapy requirements that must be met before approval.

Step 2: Call Your Insurance Provider

Speaking directly with your insurer can provide clarity on your coverage. Key questions to ask include:

• Is Tirzepatide (Mounjaro/Zepbound) covered under my plan?
• What are my out-of-pocket costs, including copays or coinsurance?
• Do I need prior authorization, and what is required to obtain approval?
• Are there alternative medications covered at a lower cost?

Step 3: Request Prior Authorization if Needed

If prior authorization is required, work with your doctor to submit supporting documentation that includes:

• Your medical history and diagnosis.
• Previous treatments tried and their effectiveness.
• A statement explaining why Mounjaro or Zepbound is the best treatment for your condition.

Step 4: Explore Manufacturer Savings Programs

Eli Lilly, the manufacturer of Mounjaro and Zepbound, offers financial assistance programs that can significantly lower costs:

• Mounjaro Savings Card – Eligible insured patients may pay as little as $25 per month.
• Zepbound Savings Card – Offers discounts for patients with commercial insurance coverage.
• Patient Assistance Programs (PAPs) – Available for uninsured or low-income individuals who qualify based on financial need.

How Much Does Tirzepatide Cost Without Insurance?

Tirzepatide is one of the most expensive diabetes and weight-loss drugs available. If you do not have insurance coverage, here are the estimated monthly costs:

Drug

Estimated Monthly Cost

Mounjaro

$1,000 – $1,200

Zepbound

$1,100 – $1,500

Ways to Lower Costs Without Insurance:

• Use manufacturer discount programs.
• Look for pharmacy coupons (GoodRx, SingleCare, etc.).
• Consider compounded Tirzepatide from specialty pharmacies (though availability and quality vary).
• Ask your doctor about alternative treatments or generic medications.

How to Maximize Your Insurance Benefits for Tirzepatide

If your insurance only partially covers or denies coverage for Tirzepatide, consider the following:

1. Appeal a Denied Claim

• Submit an appeal with medical necessity documentation.
• Include supporting evidence such as BMI records, prior treatment history, and lab results.
• Follow your insurer’s formal appeals process and timelines.

2. Use a Flexible Spending Account (FSA) or Health Savings Account (HSA)

• If your plan covers Mounjaro/Zepbound, pre-tax funds from an FSA or HSA can help offset costs.

3. Compare Insurance Plans

• During open enrollment, select a plan that offers better prescription drug coverage for GLP-1 medications.

4. Check for Employer-Sponsored Coverage

• Some employer health plans cover obesity treatments as part of wellness programs.

5. Explore State Assistance Programs

• Some state Medicaid programs provide coverage for obesity medications under specific guidelines.

TLDR

Insurance coverage for Tirzepatide depends on medical necessity and provider policies:

• Mounjaro for diabetes is more likely to be covered but may require prior authorization.
• Zepbound for weight loss faces more restrictive coverage due to insurance exclusions.
• Medicare does not cover obesity drugs, while Medicaid coverage varies by state.

To determine your eligibility, review your policy, contact your insurer, and explore financial assistance options. With careful planning, you can reduce costs and gain access to this highly effective treatment.

Follow the SuperDial Blog for more practical information, like this guide to Ozempic insurance coverage.