Does Aetna cover Zepbound?

In this article:

• Does Aetna cover Zepbound?
• How much does Zepbound cost?
• How to check if your plan covers Zepbound
• How to save on Zepbound

In this article

• Does Aetna cover Zepbound?
• How much does Zepbound cost?
• How to check if your plan covers Zepbound
• How to save on Zepbound

GLP-1 drugs like Ozempic and Wegovy might have started out as Type 2 diabetes medications, but their weight loss potential is what thrust them into the national spotlight. And Zepbound (tirzepatide) is one of the latest additions in the GLP-1 landscape, one formulated and FDA-approved specifically for weight management. In clinical trials, patients taking Zepbound lose over 20% of their body weight on average—but the question many people have is: will insurance pay for it?

Some insurance providers will cover Zepbound, including Aetna plans, but it depends on the specific plan and the patient indication. Here are all the important details.

Does Aetna cover Zepbound?

Every insurance provider is different, and most have a wide range of benefits plans, each with their own policies—so we can’t say whether Aetna does or does not cover Zepbound. Some plans might, others won’t, and it will almost always depend on your particular circumstances.

A glance through Aetna’s various formularies (drug lists) reveals that many of their plans consider Zepbound a preferred drug, which means they’re more likely to cover it. However, the beneficiary will often need to meet certain health criteria, which varies as well.

Certain plans require providers to fill out a prior authorization, which is how the insurance company confirms that a drug fits their covered criteria. That could mean the prescribing doctor has to submit additional specific documents, or it might mean trying (and failing) other drugs—like metformin, phentermine, or bupropion—before moving on to Zepbound (a process called step therapy). There might also be limits on the strength of the medication or quantity you can receive. All of that info, however, is contained in each plan’s formulary.

“I would say about 50% of the time, or more, we have to do some type of prior authorization,” estimates Dr. Supriya Rao, MD, gastroenterologist and managing partner at Integrated Gastroenterology Consultants. “And then whether or not someone needs to try and fail another drug first is around a quarter of my patients.”

Does Aetna cover Zepbound for weight loss?

There are two different medications that contain tirzepatide: Mounjaro and Zepbound. Both may help with weight and blood glucose management, but Mounjaro is solely approved for Type 2 diabetes, while its sibling Zepbound is approved for both weight loss and obstructive sleep apnea. So if an Aetna health plan covers Zepbound, they’re covering it primarily for weight management.

Yet they won’t dish out funds for every single person who wants to shed a few pounds. As noted above, Aetna members have to meet particular criteria to get coverage. Specifically, according to Aetna’s Pharmacy Clinical Policy Bulletins, patients need to:

• Undergo six months on a weight management plan that includes diet, exercise, and other behavior modification prior to taking Zepbound.
• Have a documented body mass index (BMI) of at least 30 kg/m2 OR a BMI of at least 27 kg/m2 accompanied by a diagnosis of hypertension, Type 2 diabetes, or dyslipidemia.

Aetna requires documentation of these above criteria from the healthcare provider to increase the chance that the insurance will pay for Zepbound treatment.

Doctors who are aware of these specific rules or those physicians who specialize in weight loss can help patients fulfill these requirements before prescribing Zepbound, so they can get it approved more efficiently. Insurance companies can change their criteria at any time, and it is the individual’s responsibility to review their own insurance’s formulary rules. Physicians who have extra training in obesity medicine or lifestyle medicine may be specially trained to help navigate the insurance rules. “For these patients, I teach cooking classes, and I run a lifestyle medicine curriculum through my office in a group setting,” Dr. Rao says. “So if someone is coming through my curriculum, as long as they’ve seen me for six months, then we can at least say check and say ‘yes, they are already doing this.’”

How much does Zepbound cost?

Let’s say you don’t have health insurance at all, your insurance does not cover Zepbound, or you would rather pay entirely out of pocket. What then? Without help from insurance or other sources (see below), Zebound’s average cost is around $1,499 for a pack of four 0.5ml of 2.5mg/0.5ml pens.

The good news is that many people don’t pay that full amount, either through insurance or otherwise. But receiving insurance coverage doesn’t always mean you’ll get the drug for free. Like with other insurance companies, Aetna members are responsible for paying copays and coinsurance based on how their plan classifies Zepbound and whether they’ve met their annual deductible that year.

Formularies group medications into different tiers, and insurance companies typically pay more (or all) of the cost of the drugs in the lower tiers (generic drugs) more thoroughly than those in the higher tiers (brand names, specialty drugs, etc.). As a brand-name drug, Zepbound often falls somewhere in the middle, so there’s a chance that you’ll still need to pay something, even with insurance coverage. For members whose plans don’t cover Zepbound at all, the drug’s website says patients will pay as little as $650 per month.

Even so, Dr. Rao says it’s especially important for patients to understand your plan’s rules, the tiers, and prior authorization requirements before asking a provider for a Zepbound prescription. “I think if people are really armed with that information, it makes things a lot easier. Then there are no unmet expectations,” she says.

How to check whether your Aetna plan covers Zepbound 

The plan formulary should be your go-to resource for all things prescription drug coverage, and Aetna’s member website makes it fairly easy to access their various documents. On this page, you can select your specific plan and year, then click the link that says “Go to [Your Plan Name].” There, you’ll find a database where you can search for Zepbound (or any other medication), along with a PDF of the complete formulary and other plan documents.

Or, there’s always the option of calling Aetna Inc. directly and speaking with a member support representative. Just make sure to have your insurance card and policy number on hand, since they’ll need that info to check your coverage.

How to save on Zepbound

Insurance coverage saves Americans billions of dollars on medications every year, and while it’s a solid method for saving money on Zepbound, there are ways to make it more affordable. Take SingleCare coupons, for example, which can drop Zepbound from $1,499 to $947 instantly. All you have to do is sign up for free, then send your prescription to a partnering pharmacy—and when you pick it up, show your SingleCare card to get your discount.

Dr. Rao often recommends the Lilly Direct program—which allows patients to purchase medications directly from the company at a discounted rate—along with coupon codes and patient assistance programs. Eli Lilly also has a Zepbound savings card for people with partial insurance coverage, which can drop the total out-of-pocket cost to $25 per month for some patients. People who have health benefits from Medicare, Medicaid, or other government-funded sources aren’t eligible, though.

For other reliable ways to make the medication more affordable, see our full guide on Zepbound savings.