Does Blue Cross Blue Shield Cover Zepbound?

Managing diabetes, especially type 2, is often a lifelong challenge that requires various strategies and medications. Discovering new treatments can bring hope to those managing weight and blood sugar.

One such innovation is Zepbound (tripeptide), an injectable medication approved by the FDA that has garnered attention for its dual benefits of aiding weight loss and managing blood glucose levels. But for those with a Blue Cross Blue Shield insurance plan, the pressing question remains – does my insurance cover Zepbound?

In today’s article, we’ll discuss the specifics of BCBS’s coverage policies for Zepbound. We’ll cover which plans offer this medication and how much patients might need to pay. We’ll also mention the conditions for coverage eligibility.

What is Zepbound?

Zepbound is an injectable medication that has been designed specifically for those struggling with type 2 diabetes and obesity. The FDA in the U.S. approved it on November 8, 2023. Currently, there isn’t a generic version of the medicine. It’s produced and sold by Eli Lilly and Company.

Zepbound is given to help adults lose weight and manage weight in the long run if they meet certain conditions. It’s recommended for people with:

• a body mass index (BMI) of 30 or more (classified as obese) or those with a BMI of 27 or more (considered overweight) who also have a health issue related to their weight like type 2 diabetes, high blood pressure, heart disease, high cholesterol, or sleep apnea.

How it works

Zepbound works by targeting two hormones that play a vital role in blood sugar levels – glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP).

When those hormones are activated, the body releases insulin, suppressing appetite, reducing food cravings, and slowing down digestion. As a result, patients experience weight loss and maintain a healthy blood glucose level.

Does Blue Cross Blue Shield Cover Zepbound?

Yes, Blue Cross Blue Shield (BCBS) does provide coverage for Zepbound under certain plans, especially those that include prescription drug benefits specifically designed to support conditions like type 2 diabetes and obesity.

However, the level of coverage and the out-of-pocket costs for the insured can vary significantly from plan to plan. Members are highly encouraged to review their plan details or directly contact their BCBS representative for the most accurate and up-to-date information regarding Zepbound coverage.

Also Read: Does United Healthcare Cover Zepbound?

The Cost of Zepbound – With or Without Insurance

Generally, for those with BCBS coverage, the co-payment for Zepbound can range from as low as $25 to over $100 per month, depending on the plan’s structure.

If you don’t have insurance or if your plan doesn’t cover Zepbound, it can cost a lot. A 28-day supply of Zepbound comes with a steep price tag of $1,060. Calculated over the course of a year, this amounts to an annual expense of approximately $13,800, excluding any potential savings from manufacturer discounts or financial assistance programs.

Eligibility Criteria for Zepbound Coverage

To qualify for Blue Cross Blue Shield’s coverage of Zepbound, patients must meet the following criteria:

• Diagnosed with type 2 diabetes.
• Be at least 18 years old
• Have a Body Mass Index (BMI) of 30 or higher (obese), or a BMI of 27 or higher (overweight) with at least one weight-related health issue such as high blood pressure, heart disease, or sleep apnea.
• Previously attempted weight loss through a structured program or under medical supervision without satisfactory results.
• Not currently signed up for any state, federal, or government-funded healthcare program
• A written prescription for Zepbound from a certified healthcare provider.

It’s essential for members to consult with their doctor and insurance provider to ensure they meet all necessary conditions for coverage.

Also Read: Does Kaiser Cover Zepbound for Weight Loss?

How to verify your Zepbound coverage

To verify your coverage for Zepbound under a Blue Cross Blue Shield plan, consider the following steps:

1. Use the number on the back of your insurance card to speak with a customer service representative who can provide specific details about your coverage.

2. Log in to the BCBS member website. You can find lots of helpful details there about your benefits, like specific info on prescription drug coverage.

3. If you get insurance from your job, your HR department can help you understand your healthcare benefits and what medications are covered.

4. This list shows which medicines your insurance pays for, usually found on the insurance company’s website. Zepbound will be on the list if your plan covers it.

5. Pharmacists can check if your insurance covers your prescriptions before giving them to you. They can tell you how much you need to pay for your medicine with your plan.

How can I get insurance coverage for Zepbound?

To secure insurance coverage for Zepbound, consider these steps:

• First, read through your insurance plan details. Knowing your plan helps you understand what Zepbound coverage you might have.
• Get in touch with your BCBS customer service using the info on your insurance card. They can give you personalized details about Zepbound coverage.
• Make sure all your paperwork is set, like your type 2 diabetes or obesity diagnosis, past weight loss efforts, and your Zepbound prescription.
• Check if Eli Lilly and Company, the creators of Zepbound, have any patient aid programs that can lower the cost.
• If you don’t qualify for coverage or need assistance with costs, check out other financial support options.

Factors That Determine Zepbound Coverage

Several key factors influence whether Blue Cross Blue Shield will cover Zepbound, including:

• Plan Type: The specifics of your insurance plan play a critical role. BCBS offers a variety of plans, each with different levels of prescription drug coverage.
• Location: Coverage options and health plan details can vary significantly depending on the state or region in which a member resides.
• Clinical Necessity: The patient’s medical history and current health condition must clearly indicate the need for Zepbound as a treatment for obesity and type 2 diabetes.
• Previous Treatments: Coverage may depend on whether the patient has already tried and failed to see results with other medically supervised weight loss methods.
• Regulatory Approval: Any changes or updates in FDA approvals or guidelines for Zepbound can also affect insurance coverage decisions.

Conclusion

In conclusion, Blue Cross Blue Shield does cover Zepbound in specific plans. However, the coverage level and costs may vary based on plan details and other factors. It’s important for members to check their plan specifics or reach out to their BCBS rep for accurate info on Zepbound coverage.

With this information in mind, BCBS members can make informed decisions about their healthcare and access the necessary treatment for type 2 diabetes and obesity with the help of Zepbound.

FAQ

Does Blue Cross Blue Shield cover zepbound in California?

Yes, Blue Cross Blue Shield covers Zepbound in California for qualifying plans, but the extent of coverage and the co-payment amounts vary depending on the specific plan and its terms. Members should verify their plan details for precise coverage information.

Are there any financial assistance programs for Zepbound if my Blue Cross Blue Shield plan doesn’t cover it fully?

Yes, there are financial assistance programs for Zepbound. Eli Lilly and Company, the manufacturer of Zepbound, offers a patient assistance program that may help reduce the cost for those whose Blue Cross Blue Shield plan does not fully cover it. Additionally, some third-party organizations provide financial aid or discounts for prescription medications to eligible individuals.

Is Mounjaro and Zepbound the same?

While Mounjaro and Zepbound contain the same active ingredient, tirzepatide, they are marketed under different brand names for distinct uses. Mounjaro is approved by the FDA specifically for the treatment of Type 2 diabetes, whereas Zepbound is approved for weight loss. Even though they are similar in how they are made and work, the FDA’s approval shows they are used for specific things based on studies and results.

References

• Eli Lilly and Company: Patient Assistance Programs
• U.S. Food and Drug Administration: Zepbound Approval Information