Does OptumRx cover Zepbound?

Does OptumRx cover Zepbound (tirzepatide)? Yes, sometimes. Coverage depends on your plan and whether you are taking Zepbound for weight loss or sleep apnea.

Below, find out when OptumRx typically covers Zepbound, how to check if your plan covers Zepbound, and what you can do if OptumRx will not cover your prescription.

Sometimes — OptumRx covers Zepbound for eligible patients enrolled in specific plans.

OptumRx is a pharmacy benefits manager — also known as a "middleman" — that manages prescription drug coverage for several insurance providers, including Aetna, Medicare, and UnitedHealthcare.

Ultimately, OptumRx's Zepbound coverage depends on which of the many plans you are enrolled in. It also depends on why you are taking Zepbound, since some plans cover it for obstructive sleep apnea (OSA) but not for weight loss. Eligibility, coverage, copays, and out-of-pocket caps all vary by plan.

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Does OptumRx cover Zepbound for weight loss?

Not always. Coverage depends on your plan, but many insurance plans simply do not cover GLP-1s prescribed solely for weight loss.

Currently, OptumRx does cover Zepbound (pending clinical eligibility) in plans that include:

• Zepbound on the formulary. For some plans, the list of covered medications includes Zepbound single-dose autoinjector pens and excludes Zepbound vials.

• Add-on weight loss coverage. The OptumRx Weight Engage program pairs Zepbound coverage with mandatory lifestyle counseling. You cannot simply call and add the program to your plan. The health insurance sponsor — your employer or association offering the plan — must choose to pay to add this coverage.

• Medicare Part D. Eligible patients enrolled in Medicare Part D can now get Zepbound for weight loss through the Medicare GLP-1 Bridge program. This temporary program is scheduled to end on December 31, 2027.

Does OptumRx cover Zepbound for obstructive sleep apnea?

Sometimes, yes. Insurers are more likely to cover Zepbound for obstructive sleep apnea (OSA) because Zepbound is currently the only FDA-approved OSA medication. (By contrast, there are many ways to lose weight.)

Still, some OptumRx plans exclude Zepbound coverage as a rule. That applies even if you are taking it primarily for sleep apnea rather than weight loss.

Yes, as with most insurers (e.g. Florida Blue, Kaiser, and Highmark), OptumRx typically requires prior authorization for Zepbound.

Prior authorization refers to clinical documentation your healthcare provider must submit to OptumRx to demonstrate that you meet all the criteria for Zepbound coverage.

Prior authorization for Zepbound for weight loss

Prior authorization criteria can vary by plan. As an example, OptumRx coverage of Zepbound through a UnitedHealthcare plan requires documentation showing that you:

• Are older than 16

• Have a body mass index (BMI) of 40 or higher

• Require treatment for appetite suppression, weight loss, or OSA

• Have a lifestyle modification plan, such as a reduced-calorie diet and exercise regimen.

To continue coverage for Zepbound for weight loss, OptumRx requires reauthorization after six months, then again after one year. Re-approval depends on you losing at least 5% of your starting body weight and staying committed to lifestyle changes.

Prior authorization for Zepbound for obstructive sleep apnea

The prior authorization requirements can vary by plan. In general, your healthcare provider must confirm that you are using it according to its FDA-approved use:

• You are an adult.

• You have been diagnosed with moderate to severe OSA.

• You have obesity — a BMI of 30 or higher.

The cost of Zepbound with OptumRx depends on your plan. It may also depend on whether you are taking Zepbound for sleep apnea or weight loss.

• Coverage through commercial or individual insurance: If OptumRx covers Zepbound under your plan's formulary, your out-of-pocket cost depends on the plan details. Zepbound generally falls into a higher copay tier than generic or low-cost medications.

• Coverage through OptumRx Medicare with Part D: If you are eligible for Zepbound through the Medicare GLP-1 Bridge program, you will pay $50 per month for your prescription.

The list price of Zepbound is $1,086.37 for a 28-day supply, according to Eli Lilly, the medication manufacturer. Your true out-of-pocket cost depends on insurance coverage, discounts, and whether you pay cash.

On Ro, cash payers can get the Zepbound KwikPen for $299–$449 per month (if prescribed). Cash prices are based on dose strength:

• $299 per month for the 2.5 mg dose

• $399 per month for the 5 mg dose

• $299–$449 per month for the 7.5 mg, 10 mg, 12.5 mg, and 15 mg doses, depending on manufacturer offer availability

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

Does OptumRx cover Zepbound for you? There are three simple ways to find out:

1. Check your drug formulary. Sign in to the OptumRx member portal with your HealthSafe ID. (The site will help you set up an ID if you do not have one already.) Once you are logged in, search "Zepbound" in your plan's Prescription Drug List (PDL) or drug formulary. If your plan covers Zepbound, you will see a number that represents the copay tier.

2. Call your insurer. Use the number on the back of your insurance card to ask a representative whether Zepbound is covered under your policy — and if so, whether you need prior authorization.

3. Try Ro's free GLP-1 insurance coverage checker. Enter the information on the back of your insurance card. Then, Ro will check your OptumRx benefits and give you a personalized report showing what your plan covers.

See if you qualify

OptumRx's Zepbound coverage comes down to plan and diagnosis, with no single answer that applies across the board. Here is what to remember:

• OptumRx does not have a standard policy for Zepbound. Each plan has its own rules for which medications are covered (and when), so it is important to check the details of your OptumRx policy.

• When OptumRx does cover Zepbound, it usually requires prior authorization. Your healthcare provider must submit documentation to OptumRx confirming that you meet specific criteria before your plan will cover Zepbound.

• Contact OptumRx to find out if your plan covers Zepbound. You can sign in to the online member portal, call OptumRx directly, or enter your plan information into Ro's GLP-1 insurance coverage checker.

• If OptumRx will not cover Zepbound, you still have options. People without insurance, or those who choose to pay cash, can get Zepbound (with a prescription, if eligible) with Ro's Body program.