Does TRICARE Cover Zepbound for Weight Loss?

Losing weight can be tough which impacts both of your body and mind. For military families with TRICARE, figuring out healthcare choices, especially with new medications like Zepbound, can also be really overwhelming.

In this simple guide, we will look at whether TRICARE pays for Zepbound for weight loss, how the medicine works, its costs, and what other options might be available. Keep reading to learn what you need to know about weight management choices.

What is Zepbound?

Zepbound, a new weight-loss medicine, hit the market on November 8, 2023. It has been approved by the FDA and aims to compete with other weight-loss drugs like Wegovy.

The main ingredient in Zepbound is tirzepatide, which works like two natural gut hormones—GLP-1 and GIP. These hormones are important for controlling hunger, insulin response, and how fast food leaves the stomach.

By acting like these hormones, Zepbound helps people feel fuller, leading to less calorie intake and helping with weight loss.

How It Works

Zepbound is designed for weekly administration and aims to manage obesity in adults.

• For people with a body mass index (BMI) of 30 or higher or those with a BMI of 27 or more who have health issues related to weight like high blood pressure or type 2 diabetes, Zepbound can be a helpful option.

The medication’s main function revolves around its ability to slow gastric emptying, thereby prolonging the feeling of fullness. This physiological change can lead to a natural reduction in calorie consumption, making it easier to adhere to a weight-loss regimen.

Activating GLP-1 and GIP receptors in the brain helps improve insulin sensitivity, which is especially good for people with type 2 diabetes. By helping the body manage glucose better, Zepbound can support overall metabolic health.

How much does Zepbound cost with or without insurance?

The cost of Zepbound can vary significantly depending on whether you have insurance and the specifics of your insurance plan.

Generally, if you have health insurance coverage, you might end up paying around $1,059.87 monthly for this medication. This can be a substantial financial commitment in the quest for better health and weight control.

Without insurance, the annual cost is even steeper, averaging about $13,800. However, if you have commercial insurance that covers Zepbound, you may be eligible to purchase a 1- or 3-month supply for only $25 using a Zepbound Savings Card.

Fortunately, for those concerned about these high expenses, Eli Lilly, the manufacturer of Zepbound, offers a special savings card. This card can significantly reduce the monthly costs for eligible patients, making Zepbound a more accessible option for those pursuing weight management solutions.

For people with insurance, like TRICARE, out-of-pocket costs can be much lower. However, how much is covered depends on things like the details of the insurance plan, eligibility, and if the medicine is considered necessary.

Related: Does Aetna Cover Zepbound for Weight Loss?

Does TRICARE Cover Zepbound for Weight Loss?

TRICARE coverage depends on your specific plan and eligibility. Generally, medications like Zepbound for weight loss may be covered if they are considered medically necessary.

This means a healthcare provider must prescribe Zepbound specifically for weight management issues that are seen as medical problems, like obesity or related conditions, and clearly note the need for it.

Additionally, Zepbound is included on TRICARE’s formulary list, which is great news! Active duty members can access the medication at no cost, while others will have a copay.

Coverage determination also considers FDA approval, the existence of comparable treatments, and clinical guidelines for the use of such medications. To understand if Zepbound is covered under your specific TRICARE plan, it is advisable to consult with your healthcare provider and contact TRICARE directly for personalized information and confirmation of benefits.

Eligibility Criteria for TRICARE Coverage

Zepbound could be covered by TRICARE if several conditions are satisfied:

• A candidate must have a Body Mass Index (BMI) of 30 or more, or a BMI of 27 or higher accompanied by a health issue related to their weight.
• People should have tried oral weight-loss medications like Qsymia or Contrave without success, or they should not be able to take these medications for health reasons.
• Individuals should have endeavored to lose weight through dieting and exercise for a minimum of six months without success.
• Patients must commit to maintaining healthy lifestyle habits while using Zepbound.

To get coverage, Zepbound needs approval from TRICARE, which means a healthcare provider must submit a prior authorization form. The first approval lasts for 6 months, and after that, you need to renew it every year to keep getting coverage.

Also Read: Does Kaiser Cover Zepbound for Weight Loss?

How to Get Weight-Loss Medications Covered by TRICARE

To ensure successful coverage of weight-loss medications like Zepbound under TRICARE, follow these steps:

• Talk to Your Doctor: Start by making an appointment with your doctor to discuss your weight management needs. They can decide if you need a prescription for Zepbound or another weight-loss medicine.
• Prior Authorization: Your healthcare provider must submit a prior authorization request to TRICARE. This form outlines the medical necessity of the medication, including your BMI, any related health conditions, and previous unsuccessful attempts with other weight-loss interventions.
• Formulary Check: Before proceeding, verify whether the medication is on the TRICARE formulary list. Being on this list generally facilitates easier approval and coverage process.
• Record of Past Efforts: Keep track of previous weight loss attempts, like diet plans, workout routines, or other weight-loss medicines. This record helps show why a prescription for medications like Zepbound is needed.
• Commit to Lifestyle Changes: TRICARE may require documentation that you are committed to making and maintaining lifestyle changes necessary for effective weight management in conjunction with the medication.
• Stay Informed on Renewals: Initial coverage is granted for 6 months. Ensure your healthcare provider resubmits the necessary documentation for annual renewals to maintain ongoing coverage.
• Check if your medicine is covered: Search for your medicine in TRICARE’s list of covered medications. This will help you see the coverage rules. You can also call the TRICARE Pharmacy Program at [1-877-363-1303](tel: 1-877-363-1303) if you are in the U.S., or at [1-866-275-4732](tel: 1-866-275-4732) if you are outside the U.S.

Also Read: Does Blue Cross Blue Shield Cover Zepbound?

Factors That Determine the Coverage

Understanding the factors that can influence the coverage of weight-loss medications under TRICARE is essential for a smooth approval process:

• Medical Necessity: The medication must be deemed medically necessary by a healthcare provider, which means it should address specific weight-related health conditions such as obesity or associated illnesses.
• Insurance Plan Details: Coverage may vary based on the type of TRICARE plan you hold, like TRICARE Prime, TRICARE Select, or others. Each plan has different coverage levels and requirements.
• FDA Approval: The medication must be approved by the FDA for the specific use of weight management to be considered for TRICARE coverage.
• Comparable Treatments: The existence of alternative, effective treatments may impact coverage. If other medications or therapies deemed effective are available, TRICARE might prioritize those options.
• Clinical Guidelines: Compliance with clinical guidelines for weight management therapies is crucial. These guidelines help outline appropriate treatments and ensure consistent care.
• Previous Treatment Attempts: Documentation of unsuccessful attempts at losing weight through other medications, diet, or exercise strengthens a case for needing a prescription medication like Zepbound.
• Prior Authorization: Securing coverage typically requires a prior authorization form submitted by a healthcare provider, which provides details on the necessity of the medication.
• Ongoing Treatment Check-ins: Keeping TRICARE coverage may rely on regular check-ups and notes on progress in weight management, as well as following the recommended lifestyle changes.

Alternatives and Considerations

If Zepbound is not covered by TRICARE for whatever reason, there may be other options available. It’s essential to discuss alternatives and considerations with your healthcare provider. Some potential options include:

• Behavioral Therapy: Joining behavioral therapy can help with weight management by finding triggers, creating coping strategies, and encouraging lasting lifestyle changes. This method often goes hand in hand with medication.
• Nutritional Counseling: Talking to a dietitian or nutritionist to make personalized meal plans that fit your health goals, dietary needs, and likes can help you lose weight in a healthy way.
• Physical Activity Programs: Enrolling in structured exercise programs or seeking guidance from a fitness professional helps build a routine tailored to personal capabilities and weight loss objectives.
• Surgical Options: For those not attaining desired results through diet, exercise, and medications, bariatric surgery may be an option. Such surgical interventions may provide effective weight-loss outcomes but require a thorough evaluation by a healthcare provider.
• Mindfulness Practices: Add practices like meditation or yoga can aid in managing stress and controlling emotional eating, contributing to a more balanced approach to weight management.

Conclusion

In conclusion, getting TRICARE coverage for weight-loss medications like Zepbound takes some effort. By knowing what’s needed for coverage, keeping good records, and showing dedication to lifestyle changes, people can boost their chances of getting approved.

Also, looking into other treatments makes sure there are options if medication coverage isn’t approved. Teaming up with healthcare providers and keeping up with policy changes are important steps for managing weight successfully.

FAQ

How long does Tricare cover Zepbound for weight loss?

TRICARE typically covers Zepbound for an initial period of 6 months. To continue coverage beyond this period, it’s important for your healthcare provider to submit the required documentation for annual renewals, showing that the treatment remains medically necessary and that you are adhering to recommended lifestyle changes.

What is prior authorization and why is it necessary?

Prior authorization is a process required by TRICARE that involves obtaining approval for a medication before it is dispensed. This process ensures that the medication is medically necessary and meets the coverage criteria specified by TRICARE.

How can I check if my medication is covered by TRICARE?

You can verify if your medication is covered by checking TRICARE’s list of covered medications. Additionally, you can contact the TRICARE Pharmacy Program directly at 1-877-363-1303 in the U.S. or 1-866-275-4732 outside the U.S. for more information.

Are there specific TRICARE plans that offer better coverage for weight-loss medications?

Coverage for weight-loss medications can vary depending on the TRICARE plan you have, like TRICARE Prime or TRICARE Select. It’s important to review your specific plan details or consult with TRICARE for more information about coverage levels and requirements.

What documents do I need to provide for ongoing coverage?

To keep your coverage, make sure to send in updates about your treatment and any lifestyle changes you’re following. This could mean regular check-ups with your doctor and sending updated medical records to TRICARE.

Resources

• TRICARE. (2024). Does TRICARE cover Wegovy and Ozempic?
• TRICARE. (2024). Prescription drugs.