Does United Healthcare Cover Zepbound?
Understanding health insurance and what it covers can be confusing, especially with new treatments like Zepbound for type 2 diabetes. Many people are wondering if their United Healthcare plan will cover it.
To answer this question, we first need to understand what type of treatment Zepbound is and how it fits into United Healthcare’s coverage policies.
In this blog post, we’ll break down everything you need to know in simple terms – what Zepbound is, how it might help you, and crucially, whether United Healthcare has got your back when it comes to covering the costs. Stick around as we simplify the complex world of medication coverage for you.
What is Zepbound?
Zepbound (tripeptide) is an injectable medication for managing type 2 diabetes and aiding weight loss in certain adults. The U.S. Food and Drug Administration (FDA) gave its approval on November 8, 2023. Currently, no generic form of the drug is available. It is made and marketed by Eli Lilly and Company.
Zepbound is prescribed for weight loss in adults with obesity and a body mass index (BMI) of 30 or higher, who have at least one weight-related medical condition like high blood pressure, type 2 diabetes, or high cholesterol. It is also used to help manage blood sugar levels in adults with type 2 diabetes.
How it works
Zepbound works by acting like GLP-1 (glucagon-like peptide-1), a hormone that helps manage blood sugar levels. Normally, your body releases GLP-1 after eating, triggering the release of insulin to control blood sugar.
However, in people with type 2 diabetes, this process is impaired and can cause high blood sugar levels and other complications. Zepbound helps to regulate blood sugar levels by mimicking GLP-1 and stimulating insulin release, ultimately helping to manage type 2 diabetes.
Does United Healthcare Cover Zepbound?
Good news for United Healthcare plan members managing type 2 diabetes: Zepbound will be covered from March 1, 2024. This progress is a big step for patients who could really use this new medicine but might be worried about the cost.
Usually, Zepbound could cost as much as $550 per month even with medication coupons. But, United Healthcare now helps cover this cost. Eligible patients will pay less, making this treatment more affordable. This change not only saves money but also improves healthcare for many people.
It is important to note that your United Healthcare plan’s coverage might differ based on where you are. Check with your insurance provider to know what your plan includes.
You can take a look at this update on the United Healthcare site for further confirmation.
Also Read: Does Kaiser Cover Zepbound for Weight Loss?
What is the price of Zepbound with or without insurance?
The cost of Zepbound can vary significantly depending on whether you have insurance coverage.
For those without insurance or with plans that don’t include Zepbound, the 28-day supply is priced at $1,060. This translates to an annual cost of $13,800 without insurance or discounts from the manufacturer.
For those covered by United Healthcare, starting March 1, 2024, the out-of-pocket expense for Zepbound is expected to be significantly reduced thanks to their coverage policy.
Eligible United Healthcare members might only need to pay a small part of Zepbound’s total cost, which could be as low as $25 per prescription until December 31, 2024. After this period, the cost may increase slightly but will still be significantly lower than the original price.
Eligibility criteria for Zepbound
To be eligible for Zepbound coverage under United Healthcare, individuals must meet the following criteria:
- Diagnosis of Type 2 Diabetes: Must have a formal diagnosis of type 2 diabetes from a healthcare provider.
- BMI Requirement: A body mass index (BMI) of 30 or higher for those with obesity, or a BMI of 27 or higher if accompanied by a weight-related medical condition like high blood pressure, high cholesterol, or type 2 diabetes itself.
- Previous Treatments: Must have tried at least one other diabetes medication and not achieved satisfactory control of blood sugar levels.
- Prescription by Healthcare Professional: Zepbound must be prescribed by a licensed healthcare professional who will monitor the patient’s progress and response to the treatment.
- United Healthcare Membership: Must be a current member of a United Healthcare insurance plan that includes prescription drug coverage.
- Compliance with Treatment Plan: You should demonstrate adherence to their prescribed treatment plan, including regular follow-ups and medication management as directed by your healthcare provider.
Zepbound may also be eligible for those adults who are overweight with health conditions like:
- Cardiovascular disease
- High blood pressure
- Type 2 diabetes
- Obstructive sleep apnea
- Dyslipidemia (high levels of cholesterol in the blood)
- Non-alcoholic steatohepatitis (non-alcoholic fatty liver disease)
How to verify your Zepbound coverage
To check if you can use Zepbound with United Healthcare and know what it covers, follow these steps to make it easier and understand your benefits fully.
1. Review Your Insurance Plan: First review all the important parts of your United Healthcare policy. Pay special attention to the section about prescription drug coverage. This part will explain how they cover medications like Zepbound.
2. Contact United Healthcare: Contact United Healthcare using the customer service number on your insurance card. Have your policy number and important details handy.
3. Consult with Your Healthcare Provider: Your doctor or diabetes educator can also be a great resource. They can provide documentation and support necessary for proving medical necessity, which can be crucial for coverage.
4. Check the United Healthcare Website: United Healthcare often updates its formulary (a list of covered medications) online. By checking their website, you can see if Zepbound is listed and any specific stipulations for its coverage.
5. Understand Your Out-of-Pocket Costs: Even if Zepbound is covered, it’s essential to understand your copayment, deductible, and any coverage limits. This information will help you budget for your treatment.
How can I get insurance coverage for Zepbound?
Securing insurance coverage for Zepbound starts with understanding the details of your United Healthcare plan. Follow these steps:
- Get Your Medical Records Together: Before contacting United Healthcare, collect all your medical papers like like labs, diagnoses, and prescriptions from your doctor about your type 2 diabetes and the treatments you’ve tried.
- Ask for a Letter from Your Doctor: Get a letter from your doctor explaining why Zepbound is important for you and why other treatments didn’t work well for you.
- Get Approval Before Getting the Medication: Some insurance plans, like United Healthcare, need you to get approval before you can get certain medicines. Start this process early to avoid delays.
- Fight Back if They Say No: If they say no to covering your medicine, don’t worry. You can ask them to look at it again. Your doctor can help by giving more info to support your request.
- Keep Up with Insurance Changes: Insurance rules can change, so make sure to check any new updates from United Healthcare that could affect your access to Zepbound. Check their website or call them for the latest news.
Factors that determine the coverage
Many things affect if United Healthcare pays for Zepbound, and knowing this can really help you use the coverage well. The main reasons are:
- Prescription Drug Coverage: Depending on your United Healthcare plan, they might cover different parts of your prescription costs. Some plans pay for more of the medicine costs, while others might not pay at all.
- Type of Insurance Plan: HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations) have different rules and networks that can impact your medications covered.
- Formulary Exclusions: A formulary is a list of medicines covered by your insurance plan. If Zepbound is not on the list, it might not be covered.
- Deductibles and Copayments: You might need to pay a set amount (deductible) before insurance starts covering costs. You might also have to pay a copayment or coinsurance for Zepbound.
- Medical Necessity: Insurance companies may ask for proof that the prescribed medicine is needed for your health and can’t be replaced with a cheaper option.
These factors can change from plan to plan, so it’s important to carefully review your United Healthcare policy and understand how it affects Zepbound coverage.
Conclusion
Understanding your insurance coverage is important when it comes to accessing and affording necessary medications like Zepbound. By taking proactive steps to review your policy, communicate with United Healthcare, and collaborate with your healthcare provider, you can effectively handle the complexities of insurance coverage.
Remember, staying informed and ready can really help you get the benefits you need for your health and well-being. Keep an eye out for any plan changes and speak up for your health needs.
FAQ
Does United Healthcare cover Zepbound for weight loss?
Yes, United Healthcare covers Zepbound for weight loss in adults with Medicaid plans, but coverage may vary depending on the specific plan and individual eligibility. It’s best to verify coverage directly with United Healthcare.
Are there any alternatives to Zepbound that are also covered by United Healthcare?
Yes, United Healthcare covers several alternatives to Zepbound for the treatment of type 2 diabetes and weight management. These alternatives may include other GLP-1 receptor agonists such as Trulicity, Ozempic, and Victoza are commonly included in many insurance formularies, including those of United Healthcare. But, the coverage details and costs you pay can change depending on your insurance and medical rules.
Does UnitedHealthcare cover GLP 1 for weight loss?
United Healthcare provides coverage for GLP-1 receptor agonists to aid in weight loss. The majority of UnitedHealthcare’s investment in GLP-1 drugs is directed toward managing Type 2 diabetes, while a smaller portion is allocated for weight loss purposes. This distribution is deemed satisfactory by the company as they look ahead to 2024.
