Does Kaiser cover Zepbound?

Does Kaiser cover Zepbound (tirzepatide) for weight loss? It depends on the plan. In this guide, we break down how to find out if your Kaiser Permanente plan covers Zepbound, what steps you’ll need to take to get coverage, and what to do if Kaiser won’t cover Zepbound.

Kaiser Zepbound coverage varies by region and whether your plan includes coverage for weight loss medication (not all Kaiser plans do). Even if your plan includes a weight loss benefit, Zepbound may not be covered. For example, some Kaiser plans cover Wegovy, but not Zepbound.

When Kaiser does cover Zepbound for weight loss, it's usually as a Tier 2, Tier 3, or Tier 4 medication. (Higher tiers have higher copays and stricter limits.) Prior authorization is also usually required. And, many plans may require you to try losing weight with a lower-cost weight loss pill first before they'll cover a GLP-1 such as Zepbound.

For eligible people who have a Kaiser Medicare Part D plan, the multi-dose Zepbound KwikPens are covered through the Medicare GLP-1 Bridge program, along with injectable Wegovy (semaglutide), the Wegovy pill (semaglutide), and oral Foundayo (orforglipron). The single-dose Zepbound vials and pens are not covered under this temporary program, which is scheduled to end December 31, 2027.

Traditional Medicare Part D plans may cover Zepbound when prescribed for obstructive sleep apnea (OSA) in adults with obesity.

Kaiser coverage rules and criteria for Zepbound

Kaiser Permanente coverage for Zepbound varies by region and plan. In general, Kaiser is more likely to cover Zepbound for weight loss vs. OSA. When Kaiser does cover Zepbound for weight loss, the insurer may require step therapy, prior authorization, and monthly in-office visits to monitor weight loss progress.

• Covered conditions: The FDA has approved Zepbound to treat obesity and OSA. Kaiser typically only covers Zepbound when prescribed to treat obesity, not OSA. If you have OSA and a body mass index (BMI) of 27 or higher, however, that may qualify you to take Zepbound for weight loss under Kaiser’s coverage criteria. 

• Body mass index (BMI) requirements: To get Kaiser to cover Zepbound, you must have a BMI of 30 or above, or a BMI of 27 or above and a weight-related health condition. These conditions can include OSA as well as high cholesterol, high blood pressure, type 2 diabetes, and heart disease. Calculate your BMI (for free!) here.

• Step therapy: Before covering Zepbound, Kaiser may make you try a weight loss pill first. Depending on your plan, these can include metformin, orlistat, phentermine, phentermine/topiramate, or naltrexone/bupropion. If the pills cause intolerable side effects or don’t produce enough weight loss, then Kaiser may consider approving coverage for Zepbound.

• Prior authorization: Kaiser generally requires prior authorization before covering Zepbound. This is a process your Kaiser healthcare provider will handle for you. They’ll send documentation to Kaiser to confirm you meet the coverage criteria for Zepbound and that it’s a medically necessary treatment for you.

See if you qualify

Yes, many Kaiser plans require prior authorization for Zepbound. This means your healthcare provider will need to contact Kaiser for approval before they will cover your prescription. For Kaiser to approve prior authorization for Zepbound, they may ask your provider to confirm that you:

• Have a BMI of 27 or higher with a weight-related health condition (e.g. type 2 diabetes, high cholesterol)

• Are making lifestyle changes (e.g. diet, exercise) or enrolled in a weight loss program

• Have tried another weight loss medication for at least three months and were unable to tolerate the medication’s side effects or didn’t lose 5% of your body weight

Once you’ve started taking Zepbound, your Kaiser plan may require monthly weigh-ins to monitor your progress and keep your prior authorization active.

There are four main ways you can check if your Kaiser plan covers Zepbound.

1. Use their website. On the Kaiser website, you can look up your plan’s formulary (a list of the covered drugs) to see if Zepbound is included, and if so, the coverage requirements and cost tier. You can also sign in to search for Zepbound on the drug pricing tool and see your expected copay.

2. Call Member Services. The back of your Kaiser Permanente insurance card includes a phone number for Member Services. These representatives can explain whether Zepbound is covered by your plan, outline the specific coverage criteria, and share your expected copay.

3. Ask your healthcare provider. Because Kaiser healthcare providers work in the same network as the insurance, your Kaiser provider can usually look up whether your Kaiser plan covers Zepbound. (If you’re a Ro Body member, you can also just have Ro’s insurance concierge explore coverage on your behalf.)

4. Use Ro’s GLP-1 insurance checker. With Ro’s free online GLP-1 insurance checker, you can quickly enter your plan details, and Ro will contact Kaiser for you to find out your coverage details for certain GLP-1s (including the Zepbound pen).

Zepbound’s cost with Kaiser depends on your plan. Kaiser may cover Zepbound as a Tier 2, Tier 3, or Tier 4 drug, which means it will have a higher copay than a generic medication. 

Some Kaiser plans cover Zepbound at 50% coinsurance. If you have a Medicare Part D plan with Kaiser, eligible patients can pay $50 per month for Zepbound KwikPen or select other weight loss drugs through the Medicare GLP-1 Bridge program. 

If you have a commercial Kaiser insurance plan through your work, you may qualify for the manufacturer savings offer. This Zepbound savings program brings down the cost of a monthly refill to as low as $25 per month. Eligibility restrictions apply.

If your Kaiser plan doesn't cover Zepbound, you may pay close to the list price at the pharmacy, which can range from $499–$1,086.37 per month. 

A more affordable option can be to get Zepbound on Ro, where the prices range from $299–$449 per month, depending on the dose*.

Zepbound costs as low as $25 per month with insurance and the manufacturer savings offer. It has a $50 copay with the Medicare GLP-1 Bridge program, which doesn’t count toward your deductible or out-of-pocket limit. Without insurance or pharmacy discounts, Zepbound can cost $499–$1,086.37 at the pharmacy. 

On Ro, you can get Zepbound for the following cash prices (if prescribed):

• $299 per month for the 2.5 mg dose

• $399 per month for the 5 mg dose

• $449 per month for the 7.5 mg, 10 mg, 12.5 mg, and 15 mg doses (with manufacturer offer) 

If Kaiser won’t cover Zepbound, you can try one of the following options to get Zepbound (or a similar medication) for less.

• Pay out of pocket for Zepbound. While Zepbound can cost up to $1,000 or more at the pharmacy, you can get it online for less on Ro, thanks to Ro's partnership with Eli Lilly. On Ro, Zepbound KwikPens cost $299–$449 per month, depending on the dose* (if prescribed).

• Consider a covered weight loss medication. If your Kaiser plan doesn’t cover Zepbound, but it does cover other weight loss injections like Wegovy or Saxenda (liraglutide), ask your healthcare provider if those could be a good alternative for you.

• Ask about Mounjaro or Ozempic. If you have type 2 diabetes, Mounjaro (tirzepatide) contains the same active ingredient as Zepbound in the same dosage strengths, but it is FDA-approved for diabetes. Ozempic (semaglutide) is another GLP-1 approved for type 2 diabetes. It contains the same active ingredient as Wegovy.

• Request a formulary addition or redetermination. If your Kaiser plan doesn’t cover Zepbound, you can mail in a form asking them to add it to their formulary. If your plan does cover Zepbound, but denied your prior authorization, you can appeal their denial (Kaiser calls this a “request for redetermination”).

• Switch insurance plans. If all else fails, you can switch to another insurance plan. Just double-check that your new insurance covers Zepbound, as well as any other medications you’re taking.

Fastest-working GLP-1 for faster weight loss

See if you qualify

Similar to other insurance companies — like Blue Cross Blue Shield, Aetna, and UnitedHealthcare — Kaiser Permanente’s coverage of Zepbound varies widely by region and plan.

• When Kaiser covers Zepbound for weight loss, it’s usually as a higher-tier drug.

• Kaiser typically requires prior authorization and step therapy before covering Zepbound.

• You can check if your Kaiser plan covers Zepbound by using their website, calling the number on your ID card, asking your Kaiser healthcare provider, or using Ro’s free online GLP-1 insurance checker.

• With Kaiser coverage, Zepbound may cost as low as $25 per month; without insurance, it can cost between $299 to over $1,000.

• If your Kaiser plan doesn't cover Zepbound, you can pay the cash price, consider a covered GLP-1 or weight loss medication, or request a formulary addition.

*Prices reflect a limited-time offer and are subject to change.