Tirzepatide v. Semaglutide - How to Get Tirzepatide Covered by Insurance?

Tirzepatide vs. Semaglutide Cost: Which is More Affordable?

While both medications are highly effective, their "list prices" (MSRP) without insurance are quite high.

The Verdict: Out of pocket, Tirzepatide (Zepbound) is generally slightly cheaper than Wegovy, but both usually require insurance or savings programs to be affordable for the average person.

How to Get Tirzepatide Covered by Insurance

Insurance coverage for weight loss drugs is notoriously "hit or miss." To increase your chances of coverage for Zepbound:

1. Check Your Formulary: Log into your insurance portal to see if "Anti-Obesity Medications" are excluded from your plan.

2. Meet the Criteria: Most insurers require a BMI of 1mg 30$, or 1mg  27$ with a weight-related condition (high blood pressure, Type 2 diabetes, or sleep apnea).³

3. Step Therapy: Some plans require you to try cheaper alternatives (like Phentermine) before they will approve Tirzepatide.⁴

Zepbound Prior Authorization (PA) Help

If your insurance requires a Prior Authorization, your doctor must submit documentation proving medical necessity.

• Pro Tip: Use services like Enbold or specialized telehealth providers who have dedicated teams to handle PA paperwork, as they often have higher success rates than general primary care offices.

The Cheapest Way to Get Zepbound

If your insurance denies coverage, you aren't out of luck. Here are the two most common ways to lower the price:

• The Zepbound Savings Card: Eli Lilly offers a manufacturer coupon.⁵ If you have commercial insurance that doesn't cover Zepbound, you can often get the medication for about $550/month. If your insurance does cover it, you could pay as little as $25.

• LillyDirect: Eli Lilly recently launched a direct-to-consumer portal that partners with digital pharmacies to ensure patients get the lowest possible price without pharmacy markups.⁶

Tirzepatide Compounding Pharmacies: A Lower-Cost Alternative?

Due to the ongoing FDA shortage of Tirzepatide, many patients have turned to compounding pharmacies.

• Cost: Compounded Tirzepatide typically costs between $250 and $450 per month, significantly less than the Zepbound retail price.

• Legality: Compounding is legal when a drug is on the FDA shortage list.⁷

• Safety: Only use pharmacies that are PCAB-accredited and require a valid prescription. Avoid "research chemical" websites, as these substances are not regulated for human use.

Best Telehealth for Tirzepatide

If your local doctor isn't familiar with GLP-1s, telehealth is a streamlined way to get a prescription.⁸ Popular options include:

• Ro & Calibrate: Comprehensive programs that include coaching and insurance assistance.

• Sequence (WeightWatchers): Known for robust insurance coordination and PA support.

• Mochi Health: Offers flat-rate pricing for compounded options if insurance fails.

Frequently Asked Questions (FAQ)

1. Is compounded Tirzepatide still legal and safe? As of late 2024, the FDA removed Tirzepatide from the official drug shortage list, which technically restricted mass compounding. However, due to ongoing litigation and "intermittent" supply issues, many pharmacies still offer it. While often 50–70% cheaper than brand-name drugs, compounded versions are not FDA-approved, meaning their potency and purity aren't verified by the government. Always choose a PCAB-accredited pharmacy to minimize risk.

2. Can I get Zepbound for $25 if my insurance doesn't cover it? Generally, no. The $25 per month price is typically reserved for those with commercial insurance that already covers the drug. If your insurance specifically excludes weight loss medications, the Eli Lilly Savings Card usually brings the price down to around $550, which is still a significant discount from the $1,060 retail price.

3. Does Medicare or Medicaid cover Tirzepatide for weight loss? Standard Medicare Part D plans are currently prohibited by law from covering medications used strictly for weight loss. However, if you are prescribed Tirzepatide (as Mounjaro) for Type 2 Diabetes or (as Zepbound) for severe obstructive sleep apnea, coverage is much more likely. Medicaid coverage varies by state, with some states now adding GLP-1s to their preferred drug lists.

4. What are the "hidden costs" of using telehealth for weight loss? When calculating your budget, remember that the telehealth subscription fee (ranging from $50 to $130/month) usually does not include the cost of the medication itself. Additionally, you may need to pay out-of-pocket for baseline lab work (blood tests) to check your thyroid and kidney function before a provider will issue a prescription.

5. How long does it take for a Prior Authorization (PA) to be approved? Once your doctor submits the paperwork, most insurance companies respond within 3 to 7 business days. If the initial request is denied, the appeal process can take an additional 30 days. Using a telehealth provider with a dedicated "insurance advocacy" team can often speed this up by ensuring all clinical data (like your BMI and previous weight loss attempts) is submitted correctly the first time.