Zepbound is a widely used medication for weight loss. Many people with Express Scripts pharmacy benefits want to know if it’s covered. This article explains Express Scripts’ coverage for Zepbound, costs, and how to check your plan. We’ll keep it simple and easy to understand.
What Is Zepbound?
Zepbound is a prescription drug for weight loss. It’s approved for adults with obesity or overweight conditions. The medication is used with diet and exercise. It’s injected under the skin once a week.
Zepbound contains tirzepatide, which helps reduce appetite. It’s also used for type 2 diabetes under the brand Mounjaro. Made by Eli Lilly, Zepbound is effective for weight management. It’s popular due to its proven results.
About Express Scripts
Express Scripts is a pharmacy benefit manager (PBM). It handles prescription drug coverage for millions. Many employers and health plans use Express Scripts. Coverage depends on your specific plan.
Express Scripts maintains a formulary, or list of covered drugs. This list varies by plan and employer. Some plans cover weight loss drugs, while others don’t. Zepbound’s coverage isn’t guaranteed and requires checking.
Does Express Scripts Cover Zepbound?
Whether Express Scripts covers Zepbound depends on your plan. In 2023, Express Scripts added Zepbound to its National Preferred Formulary. However, individual plans may still exclude it. Employers can opt out of weight loss drug coverage.
Zepbound often requires prior authorization. This means your doctor must prove it’s medically necessary. Coverage rules may include a high BMI or related health conditions. Check your plan to confirm Zepbound’s status.
To find out, use Express Scripts’ online tools. Log in to your account and check the formulary. You can also call Express Scripts or ask your pharmacist. Coverage details are specific to your employer or plan.
How to Check Zepbound Coverage
Checking if Express Scripts covers Zepbound is straightforward. You’ll need your plan details, like your member ID. Here’s how to verify coverage:
- Log In Online: Visit express-scripts.com. Use the “Price a Medication” tool to check Zepbound.
- Call Express Scripts: Use the number on your prescription card. Ask about Zepbound coverage.
- Ask Your Doctor: They can contact Express Scripts. They may start prior authorization if needed.
- Visit a Pharmacy: In-network pharmacists can check coverage. Bring your Express Scripts card.
Coverage varies by plan. For example, some plans cover Zepbound for $110 for a 3-month supply. Others list it as non-covered. Always confirm with Express Scripts directly.
Prior Authorization for Zepbound
Many Express Scripts plans require prior authorization for Zepbound. Your doctor submits a form to Express Scripts. They explain why Zepbound is needed, like obesity or related conditions. Express Scripts reviews the request.
The process may take a few days. Requirements often include a BMI over 30 or 27 with comorbidities. Some plans ask for proof of failed treatments, like metformin. If approved, coverage follows your plan’s rules.
If denied, Express Scripts sends a denial letter. The letter explains the reason and appeal options. Your doctor can help with the prior authorization process. Stay in touch to track progress.
Costs of Zepbound with Express Scripts
Zepbound’s cost varies by plan. Express Scripts assigns drugs to tiers, affecting copays. Zepbound is often a high-tier or specialty drug. This means higher copays or coinsurance.
With coverage, costs might range from $68 to $110 for a 3-month supply. Without coverage, Zepbound costs about $1,059 monthly. Your deductible or out-of-pocket maximum also impacts costs.
Check your plan’s benefits summary. This shows copays, tiers, and deductibles. Use Express Scripts’ “Price a Medication” tool for exact pricing. Costs depend on your employer’s plan design.
Zepbound Savings Programs
Eli Lilly offers savings options for Zepbound. If you have commercial insurance, a copay card may reduce costs. Eligible patients pay as low as $25 monthly. However, Express Scripts plans may not always qualify.
For non-covered plans, Lilly’s Self Pay Journey Program offers discounts. A 1-month supply of Zepbound vials costs $349-$499, depending on the dose. This is for cash-paying patients without coverage.
Visit Lilly’s website or call 1-844-559-3471 for details. Confirm with Express Scripts if savings programs apply. Some pharmacies may not process coupons if Express Scripts offers a discount.
Table: Zepbound Costs With and Without Express Scripts
| Scenario | Approximate Cost | Details |
|---|---|---|
| No Coverage (Full Price) | $1,059/month | Cost for a 30-day supply of 4 pens without insurance. |
| Express Scripts Coverage | $68-$110/3 months | Varies by plan; assumes prior authorization approval. |
| Lilly Copay Card | $25/month | For eligible commercial plans; up to 13 fills per year. |
| Lilly Self Pay Program | $349-$499/month | For cash payments; vial pricing varies by dose (2.5 mg to 10 mg). |
Note: Costs are approximate for 2025. Verify with Express Scripts for exact pricing.
Alternatives to Zepbound
If Express Scripts doesn’t cover Zepbound, alternatives exist. Your doctor can recommend other weight loss drugs. Some may be on your formulary with fewer restrictions. Common options include:
- Wegovy: An injectable drug for weight loss, often covered with prior authorization.
- Saxenda: Another weight loss medication, sometimes on formularies.
- Phentermine: A lower-cost oral drug for short-term use.
Generic drugs are often cheaper and more likely covered. If Zepbound is denied, ask about formulary options. Your doctor can request an exception for Zepbound if needed.
Using Express Scripts’ Pharmacy Network
Express Scripts requires in-network pharmacies for coverage. These pharmacies process claims at the lowest cost. Use Express Scripts’ “Find a Pharmacy” tool online. Enter your ZIP code to locate one.
Express Scripts Pharmacy offers home delivery. A 90-day supply can save money and time. Maintenance drugs like Zepbound are ideal for home delivery. Ask your doctor to send prescriptions to Express Scripts.
Always use your Express Scripts ID card at pharmacies. Out-of-network pharmacies may not be covered. This could lead to higher costs or claim rejections.
Appealing a Coverage Denial
If Express Scripts denies Zepbound, you can appeal. The denial letter explains the reason and appeal process. Your doctor can submit an appeal letter. It should include medical records or justification.
Appeals are reviewed by a doctor, not a computer. Success rates for appeals range from 39-59%. Provide detailed health information, like BMI or comorbidities. Express Scripts will notify you of the outcome.
Work closely with your doctor during appeals. They can provide necessary documents. Call Express Scripts for updates on your appeal status. If denied again, explore alternatives or savings programs.
Tips for Managing Zepbound Costs
Managing Zepbound costs with Express Scripts takes planning. Here are some ways to save:
- Check your formulary before starting Zepbound.
- Use home delivery for 90-day supplies.
- Explore Lilly’s savings programs if eligible.
- Consider generics or formulary alternatives.
Use a Health Savings Account (HSA) or Flexible Spending Account (FSA) if available. These can cover copays or deductibles. Review your plan’s benefits to avoid unexpected costs.
Summary
Express Scripts may cover Zepbound, but it depends on your plan. Check your formulary or use the “Price a Medication” tool to confirm.
Prior authorization is often required, and costs vary by plan tier. Lilly’s savings programs can help if coverage is limited. If denied, appeal or consider alternatives like Wegovy. Use in-network pharmacies or home delivery to save money.
FAQ
Does Express Scripts cover Zepbound for weight loss?
Coverage depends on your plan’s formulary. Zepbound is on the National Preferred Formulary but may need prior authorization. Check with Express Scripts to confirm.
How much does Zepbound cost with Express Scripts?
With coverage, costs range from $68-$110 for a 3-month supply. Without coverage, it’s about $1,059 monthly. Use the “Price a Medication” tool for exact costs.
What if Express Scripts denies Zepbound coverage?
You can appeal with your doctor’s help. The denial letter includes appeal instructions. Alternatives like Wegovy or Saxenda may be covered.
Can I use Lilly’s savings card with Express Scripts?
Lilly’s $25 copay card works for commercial plans. Some Express Scripts plans may not qualify. Contact Lilly or Express Scripts to verify.
How do I get Zepbound through Express Scripts?
Use an in-network pharmacy or Express Scripts’ home delivery. Ensure prior authorization is approved. Bring your Express Scripts card to the pharmacy.