Does Medicaid Cover Zepbound for Weight Loss?

Obesity affects millions of Americans, leading to serious health issues like diabetes and heart disease. Zepbound, a new weight-loss drug, has gained attention for its effectiveness. Many people wonder, “Does Medicaid cover Zepbound for weight loss?” This article explains Medicaid coverage for Zepbound in simple terms.

What Is Zepbound?

Zepbound is a brand-name drug made by Eli Lilly. Its active ingredient, tirzepatide, helps people lose weight by reducing appetite. The FDA approved Zepbound in 2023 for weight loss in adults with obesity.

Zepbound is also approved for obstructive sleep apnea (OSA). It’s similar to Mounjaro, a drug used for diabetes. Both share the same active ingredient but have different approved uses.

How Does Zepbound Work?

Zepbound mimics a hormone called GLP-1, which controls hunger. It slows digestion, making you feel full longer. This leads to reduced food intake and weight loss.

Studies show Zepbound can help people lose 15% to 25% of their body weight. It’s given as a weekly injection. A doctor’s prescription is needed to use it.

Medicaid and Weight-Loss Drugs

Medicaid is a federal and state program for low-income individuals. It covers many medical services, including prescription drugs. However, coverage for weight-loss drugs like Zepbound is not guaranteed.

Federal law allows states to decide whether to cover weight-loss medications. This means coverage for Zepbound varies by state. Some states cover it, while others don’t.

Current Medicaid Coverage for Zepbound

As of 2025, Medicaid coverage for Zepbound depends on the state and the condition being treated. Zepbound is often covered for OSA if the manufacturer participates in the Medicaid Drug Rebate Program. However, coverage for weight loss is less common.

At least 14 states, including Pennsylvania and North Carolina, cover Zepbound for weight loss. These states require prior authorization, meaning doctors must prove the drug is medically necessary. Other states may exclude Zepbound for weight loss due to high costs.

Why Coverage Varies by State

Medicaid programs are managed by individual states. Each state sets its own rules for drug coverage. Some states prioritize covering Zepbound for weight loss to improve public health.

Others avoid covering it because of the drug’s high cost. A monthly supply of Zepbound can cost over $1,000 without insurance. This makes it expensive for state budgets.

States That Cover Zepbound for Weight Loss

Several states have started covering Zepbound for weight loss under Medicaid. These states recognize obesity as a chronic disease. Here are some examples:

• Pennsylvania: Covers Zepbound with prior authorization for adults with a BMI of 30 or higher.
• North Carolina: Covers it for beneficiaries aged 12 and older since August 2024.
• California: Includes Zepbound in its Medicaid program with strict criteria.

At least 11 other states, like Michigan and Virginia, also cover Zepbound. Check with your state’s Medicaid office for details.

Conditions for Coverage

States that cover Zepbound for weight loss often have strict rules. Patients usually need a BMI of 30 or higher. Some states require a BMI of 27 with health issues like hypertension.

Prior authorization is common. Doctors must submit proof that Zepbound is needed. Some states may also require patients to try diet and exercise first.

Cost of Zepbound Without Coverage

Without Medicaid coverage, Zepbound is expensive. The list price is around $1,086 per month. This makes it unaffordable for many low-income individuals.

Some patients may qualify for Eli Lilly’s savings program. However, this program excludes those with government insurance like Medicaid. Out-of-pocket costs can be a major barrier.

Table: Zepbound Coverage by Selected States (As of 2025)

This table shows how coverage varies. Always verify with your state’s Medicaid program.

Proposed Changes to Medicaid Coverage

In November 2024, the Biden administration proposed a rule to expand Medicaid coverage for weight-loss drugs. This rule would cover Zepbound for obesity treatment. It aimed to help 4 million Medicaid beneficiaries.

The Trump administration, starting in 2025, decided not to move forward with this rule. This means coverage remains state-dependent. Future policy changes could still happen.

Why Zepbound Matters for Obesity

Obesity is a major health issue in the U.S. It increases the risk of heart disease, stroke, and diabetes. Medicaid coverage for Zepbound could help reduce these risks.

Zepbound offers hope for those struggling with weight loss. It’s more effective than diet and exercise alone for many people. Coverage could improve health outcomes for low-income individuals.

Challenges of Covering Zepbound

Covering Zepbound is costly for Medicaid programs. States worry about budget impacts. For example, Pennsylvania’s coverage is projected to cost $1.3 billion in 2025.

There are also concerns about drug shortages. High demand for Zepbound has led to supply issues. Increased Medicaid coverage could worsen this problem.

How to Check If Your State Covers Zepbound

To find out if Medicaid covers Zepbound in your state, contact your state’s Medicaid office. You can also ask your doctor or pharmacist. They can check your state’s preferred drug list.

If Zepbound isn’t covered, your doctor may suggest other options. These could include cheaper medications or lifestyle programs. Always discuss alternatives with your healthcare provider.

What If Zepbound Isn’t Covered?

If Medicaid doesn’t cover Zepbound for weight loss, you have options. Some states cover other weight-loss drugs like Saxenda or Wegovy. Your doctor can help you explore these.

You can also appeal a denial of coverage. Contact your state’s Medicaid office for appeal instructions. Organizations like the Pennsylvania Health Law Project can assist.

Health Benefits of Weight Loss

Losing weight with Zepbound can improve your health. It can lower blood pressure and reduce diabetes risk. Patients have reported losing 20 to 60 pounds with GLP-1 drugs.

Weight loss also improves mental health. Feeling better about your body can boost confidence. Medicaid coverage for Zepbound could make these benefits accessible to more people.

Risks and Side Effects of Zepbound

Zepbound is effective but has side effects. Common ones include nausea, diarrhea, and fatigue. Some patients experience more serious issues like gallbladder problems.

Your doctor will monitor you while taking Zepbound. They’ll ensure the benefits outweigh the risks. Always report side effects to your healthcare provider.

The Future of Zepbound Coverage

Medicaid coverage for Zepbound may expand in the future. More states are considering covering weight-loss drugs. Public health advocates support this to address obesity.

However, cost remains a barrier. Policymakers must balance health benefits with budget concerns. Changes in federal policy could also affect coverage.

Summary

Zepbound is a powerful weight-loss drug that helps many people manage obesity. Does Medicaid cover Zepbound for weight loss? It depends on your state. Some states, like Pennsylvania and North Carolina, cover it with prior authorization, while others don’t due to high costs. Contact your state’s Medicaid office to check coverage. If Zepbound isn’t covered, explore other options with your doctor. Future policy changes may increase access to this drug.

FAQ

Does Medicaid cover Zepbound for weight loss in all states?
Coverage varies by state. At least 14 states cover Zepbound for weight loss, but others don’t. Check with your state’s Medicaid office for details.

What is the cost of Zepbound without Medicaid?
Zepbound costs about $1,086 per month without coverage. Manufacturer savings programs may help, but they don’t apply to Medicaid patients.

What are the requirements to get Zepbound covered?
Most states require a BMI of 30 or higher and prior authorization. Some also ask for proof of diet or exercise attempts.

Can I appeal if Medicaid denies Zepbound coverage?
Yes, you can appeal a denial. Contact your state’s Medicaid office or a legal aid group like the Pennsylvania Health Law Project for help.

Are there other weight-loss drugs covered by Medicaid?
Some states cover drugs like Saxenda or Wegovy. Ask your doctor about alternatives if Zepbound isn’t covered.