Does Fidelis cover Zepbound?

Anyone interested in Zepbound (tirzepatide) for weight loss or sleep apnea is probably also wondering about Zepbound insurance coverage. Does Fidelis cover Zepbound? It depends on the plan.

This article covers what you need to know about Fidelis coverage for Zepbound, including the typical Zepbound cost with and without insurance coverage. 

Fidelis may cover Zepbound, but it depends on your plan. Like Florida Blue, Aetna, and Humana, Fidelis does not have a one-size-fits-all policy on Zepbound coverage. Each plan has its own drug formulary, the list of covered medications.

Even if your plan's drug formulary includes Zepbound, coverage may depend on why you are taking it. Zepbound is only FDA-approved for two uses: weight loss and obstructive sleep apnea (OSA).

Does Fidelis cover Zepbound for weight loss? Not typically — though people enrolled in Medicare Part D are a temporary exception.

• Commercial/employer/individual plans: Many Fidelis plans specifically exclude coverage of weight loss medications. Others simply do not include Zepbound on the formulary.

• Fidelis Medicare plans: Eligible Fidelis Medicare Part D enrollees might be able to get the Zepbound KwikPen for weight loss through the Medicare GLP-1 Bridge program, which is scheduled to end December 31, 2027.

• Fidelis Medicaid plans: Enrollees receive prescription drug benefits through NYRx, which does not cover Zepbound for weight loss.

Does Fidelis cover Zepbound for sleep apnea? Coverage still varies by plan, but it is more likely.

• Fidelis Medicare plans: Medicare covers Zepbound for sleep apnea for people who meet all the eligibility criteria.

• Fidelis Medicaid plans: With NYRx pharmacy benefits, Zepbound is covered (in limited quantities) for eligible patients who have OSA and obesity.

• Other Fidelis plans: Some Fidelis plans do not include Zepbound no matter what, but coverage varies by plan.

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Fidelis coverage for Zepbound: rules and criteria 

Even if your Fidelis plan formulary lists Zepbound as a covered medication, you may still need to follow strict rules or meet eligibility criteria to get coverage.

Stipulations may include:​

• Prior authorization. Your healthcare provider may need to send Fidelis paperwork explaining why Zepbound is medically necessary before the plan will pay for it. In insurance terms, this is called prior authorization.

• Trying a lower-cost medication first. This is called step therapy, and insurance sometimes requires it before covering expensive medications such as weight loss injections.

• Medicare Part D enrollment. To get Zepbound through the Medicare GLP-1 Bridge program, your Fidelis plan must include Medicare Part D, the optional benefit that covers outpatient prescription drugs.

Yes, Fidelis requires prior authorization for all GLP-1s, including Zepbound. 

As with other insurers (such as BCBS or Cigna), prior authorization means that your healthcare provider needs to submit documents to Fidelis confirming why you need Zepbound before your plan will cover it.

Prior authorization for Zepbound for weight loss

Prior authorization requirements can vary by plan. For Zepbound through the Medicare GLP-1 Bridge program, documentation must show that you are an adult with one of the following:​

• A body mass index (BMI) of 35 or higher

• A BMI of 30 or higher plus at least one of these diagnoses:

  • Heart failure

  • Uncontrolled high blood pressure

  • Advanced-stage kidney disease

• A BMI of 27 or higher plus at least one of these: 

  • Prediabetes

  • History of heart attack or stroke

  • Peripheral artery disease

Prior authorization for Zepbound for sleep apnea

Exact requirements can vary by plan. If you have a Fidelis Medicaid plan, prior authorization for Zepbound for sleep apnea must show that you:​

• Have an obstructive sleep apnea diagnosis

• Have a BMI of 40 or higher

• Are participating in a diet and exercise plan

There are three quick ways to find out:

1. Call Fidelis. Phone the number on the back of your insurance card and ask whether Zepbound is covered under your Fidelis plan. If so, ask whether there are eligibility criteria.

2. Check online. Sign in to the Fidelis Care member portal to see your plan's drug formulary. Search for Zepbound to see if it is covered under your plan — and, if so, whether there are criteria you have to meet.

3. Use Ro's free GLP-1 insurance coverage checker. Fill out the form with your insurance details, and Ro will contact Fidelis for you. You will get a free insurance coverage report with the results.

It depends on your plan. 

• Fidelis Medicare plans: If you have a Fidelis Medicare plan with Part D coverage and qualify for the Medicare GLP-1 Bridge program, you will pay $50 per month for the Zepbound KwikPen.

• Fidelis Medicaid plans: If your Medicaid plan covers Zepbound for sleep apnea, your copay depends on your state and specific policy.

• Other Fidelis insurance: If you have a Fidelis commercial insurance plan that covers Zepbound, you may be able to pay as little as $25 per month with Eli Lilly's savings card.

The list price for Zepbound is $1,086.37 per month. That is without insurance, financial assistance, or cash-pay discounts.

Cash payers — including those without insurance coverage — can get Zepbound for $299–$449 per month (varies by dose strength) with Ro's Body Membership.*

* Prices may reflect limited-time offers and are subject to change; see more here.

If Fidelis will not cover your Zepbound prescription, you can still:

• Appeal to Fidelis to reconsider. If Fidelis denies Zepbound coverage, your healthcare provider has 65 days to submit an appeal asking Fidelis to reconsider. Fidelis can still deny coverage, but it must let you know the final decision within 30 days.

• Consider a different GLP-1. In some cases, Fidelis may cover a different, similar medication, such as Wegovy (semaglutide) or Mounjaro (tirzepatide). Ask your healthcare provider if there is another GLP-1 that might meet your medical needs and health goals — then check to see if Fidelis covers that Zepbound alternative.

• Opt to pay cash. Cash payers can get Zepbound KwikPens on Ro for as little as $299 per month at the starting dose. Getting Zepbound on Ro requires a telehealth appointment and a prescription (if eligible).

See if you qualify

Whether Fidelis covers Zepbound comes down to your specific plan and the reason for your prescription.

• Fidelis rarely covers Zepbound for weight loss. Some plans, including Fidelis Medicaid plans, exclude weight loss medications — but for a limited time, eligible Fidelis Medicare enrollees with Part D may be able to get Zepbound through the Medicare GLP-1 Bridge program.

• Some Fidelis plans may cover Zepbound for sleep apnea under Medicaid and Medicare Part D.

• It is easy to find out if your Fidelis plan covers Zepbound. Log in to the member portal, call the number on the back of your insurance card, or use Ro's GLP-1 insurance coverage checker.

• If Fidelis will not cover Zepbound, you still have options. You can try to appeal the denial, switch to a different medication, or save on the retail price by paying cash.