Does Kaiser cover Zepbound?

In this article:

• Does Kaiser Permanente cover Zepbound?
• Does Kaiser cover tirzepatide?
• How much does Zepbound cost?
• How much does Zepbound cost with Kaiser?
• How to check whether your Kaiser plan covers Zepbound
• How to save on Zepbound

In this article

• Does Kaiser Permanente cover Zepbound?
• Does Kaiser cover tirzepatide?
• How much does Zepbound cost?
• How much does Zepbound cost with Kaiser?
• How to check whether your Kaiser plan covers Zepbound
• How to save on Zepbound

Zepbound (tirzepatide) is a medication approved by the Food and Drug Administration (FDA) to treat obesity and obstructive sleep apnea (OSA) in combination with a reduced-calorie diet and increased exercise. It is known as a GIP/glucagon-like peptide-1 receptor (GLP-1) agonist and has the same active ingredient as Mounjaro (tirzepatide). 

With Zepbound’s retail prices averaging $1,524 per month, having insurance coverage can help significantly. However, coverage for weight loss drugs is somewhat limited. 

Does Kaiser Permanente cover Zepbound?

Some Kaiser Permanente insurance plans cover Zepbound for weight loss or OSA. Coverage varies by region, plan, and whether you meet certain criteria. For example, Kaiser Northwest members may have Zepbound coverage for weight loss if they: 

• Have a diagnosis for chronic weight management
• Are 18 years or older
• Have a body mass index (BMI) greater than or equal to 30 kg/m2 (classified as obesity) or 27 kg/m2 (classified as overweight) and have a diagnosis of high blood pressure, diabetes, or high cholesterol
• Are following a diet and exercise program
• Have previously tried at least two drugs such as phentermine, diethylpropion, Qsymia (phentermine/topiramate), or Contrave (naltrexone/bupropion) without success (or cannot take or tolerate other drugs)
• Tried semaglutide (Wegovy or Ozempic) and it didn’t work, or they can’t take semaglutide due to an allergy, serious side effects, or contraindication

The same Kaiser plan may cover Zepbound for OSA for members who are 18 or older who have obesity and meet all of the following criteria:

• Have no personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2
• Have been diagnosed with severe sleep apnea but does not central or complex apnea
• Have had a sleep study within the three past years
• Are following a diet and exercise program
• Have tried other preferred medications or have allergies to them

Some Kaiser plans may also require your healthcare provider to submit prior authorization before the drug is covered. 

If a Kaiser Permanente member doesn’t have Zepbound on its covered drug formulary, they will have to pay the cash price for the medication or use prescription discount cards or coupons to save. 

Does Kaiser cover tirzepatide?

The active ingredient in Zepbound, tirzepatide, is also found in the drug Mounjaro, an FDA-approved drug for Type 2 diabetes. Some Kaiser Permanente plans cover Mounjaro but not Zepbound. For example, Kaiser Permanente Insurance Company (KPIC) plans in California may cover Mounjaro for managing diabetes. 

Due to cost, limited insurance coverage, and previous drug shortages, some people may consider compounded tirzepatide as an alternative to Zepbound. Katherine Saunders, MD, co-founder of FlyteHealth and obesity medicine specialist at Weill Cornell Medicine in New York City, explains, “The lack of coverage, high cost, and drug shortages are tremendous barriers to tirzepatide access right now, so many patients ask about compounded medications.” However, that doesn’t mean it is safe or even legal.

Compounded tirzepatide is made by compounding pharmacies rather than a pharmaceutical company. Unlike Zepbound and Mounjaro, it is not FDA approved and is unlikely to be covered by insurance. The FDA previously allowed compounded tirzepatide to be made due to a national shortage, but that shortage has been resolved, and pharmacies and outsourcing facilities are no longer allowed to compound, distribute, or dispense compounded GLP-1 medications, including tirzepatide.

How much does Zepbound cost?

Zepbound’s list price from its manufacturer, Lilly, is $1,086.37 per month, but most people don’t pay the list price. Instead, they pay the average retail price, which fluctuates and varies by pharmacy and location. Without insurance, the average retail price of Zepbound is $1,524 per 4, 0.5 mL of 2.5 mg/0.5 mL single-dose injector pens—which is a 28-day supply. 

How much does Zepbound cost with Kaiser?

The cost of Zepbound with Kaiser Permanente varies by insurance plan, but can be as low as $25. Kaiser insurance plans have formularies that list covered drugs and categories of coverage from Tier 1 to specialty medication. For example, Zepbound can cost $45 to $65 per month with certain Kaiser Permanente Federal Employee Health Benefits (FEHB) plans.

According to Lilly, the manufacturer of Zepbound, someone with a commercial drug insurance plan that covers Zepbound may pay as low as $25 for a one- or three-month supply of Zepbound. You can check the manufacturer’s website for more information and eligibility requirements.

RELATED: Does Aetna cover Zepbound?

How to check whether your Kaiser plan covers Zepbound 

Kaiser plans may provide a formulary so members can see whether their drugs are covered. Kaiser’s website organizes its covered drug lists by region and plan. You can also log in to your Kaiser Permanente portal online or contact customer service to check whether your Kaiser plan covers Zepbound.

If your insurance plan doesn’t cover a drug, that doesn’t mean that you can’t receive care. “Not having insurance coverage for GLP-1 medications does not mean that an individual can’t receive extremely effective and sustainable medical obesity care,” Dr. Saunders states. Your healthcare professional can provide all the treatment options that are best for you. 

Learn more about Zepbound alternatives for weight loss. 

How to save on Zepbound

There are ways to save on Zepbound even if your Kaiser plan doesn’t cover it. SingleCare offers prescription discounts on Zepbound at participating pharmacies using its free Prescription Discount Card. With SingleCare, you can pay as low as $945 for 4, 2.5 mg/0.5 mL single-dose injector pens. That’s $579 less than you’d pay without a SingleCare coupon.