The news about the new weight loss drug, Zepbound, is exciting. It may be a lifesaver for many people with obesity who have tried in vain for years or decades to lose weight and keep it off.
However, not everyone can access this medication. People are paying huge amounts of money to get it. And for a drug that must be taken consistently to see results, many people cannot afford to pay out of pocket.
Luckily, some insurance companies are covering Zepbound. Tricare, a healthcare program for military personnel and their families, covers the cost.
In this blog post, we will explore Tricare coverage criteria for Zepbound and provide all the information you need.
What Is Zepbound?
Zepbound is an injectable medication approved by the FDA that may help people with obesity or overweight who also have weight-related medical conditions lose weight and keep it off.
Eli Lilly, the manufacturer of this drug, advises using it with a low-calorie diet and increased physical activity.
Zepbound works by suppressing hunger and reducing food intake by stimulating glucagon-like peptide 1 (GLP1) receptors and glucose-dependent insulinotropic polypeptide (GIP), the hormones the intestine secretes during digestion.
In addition to suppressing hunger, GLP-1 agonists such as Zepbound may slow stomach emptying, prolonging the time it takes for the body to absorb nutrients and helping improve blood sugar regulation by promoting increased insulin production.
Zepbound contains tirzepatide, which the FDA has also approved under the brand name Mounjaro, to help improve blood sugar levels in people with type 2 diabetes.
You should not use Zepbound alongside other tirzepatide-containing drugs like Mounjaro or any GLP-1 receptor agonist medicines like Ozempic and Wegovy.
Does Tricare Cover Zepbound?
Tricare may cover Zepbound for weight loss, but only if you are enrolled in TRICARE Prime or Select and meet strict clinical criteria, such as a BMI greater than or equal to 30 or greater than or equal to 27 with comorbidities and failed prior weight-loss attempts. You can consult our healthcare professional at NP2GO to help determine your coverage options.
Zepbound requires TRICARE authorization through the coverage review process. This is when your prescriber sends in a prior authorization form to TRICARE. At NP2GO, we can help you fill out the form and submit it.
Zepbound’s approval is temporary and lasts 6 months. You’ll need to renew the authorization every 12 months.
Tricare Coverage Criteria for Zepbound
Tricare covers Zepbound, but only if you meet specific requirements. Here are some essentials to consider:
- To be approved for coverage, you must meet the FDA-approved requirements for Zepbound, which include having a BMI of 30 or higher or a BMI of 27 or higher, along with at least one weight-related condition like cardiovascular disease (CVD), type 2 diabetes, obstructive sleep apnea, hypertension, or impaired glucose tolerance.
- You must also have tried and failed or have contraindications to Qsymia, Contrave, and Phentermine.
- Tricare may require you to complete a prior authorization request form for Zepbound. Our healthcare practitioner will help you submit this request to Tricare for approval before you can start using the medication.
- Before receiving Zepbound coverage, Tricare requires its members to try lifestyle changes through diet and exercise for at least 6 months.
- The insurance company also wants customers to follow a low-calorie diet and work out. You can use a calorie calculator to estimate the daily calories your body needs to lose or maintain weight.
How to Access Zepbound Through Tricare
Navigating TRICARE’s pharmacy benefits can be overwhelming, but you don’t have to do it alone. At NP2GO, we specialize in helping military families in Oklahoma and across the U.S. access life-changing weight-loss medications like Zepbound.
Here is our streamlined process for getting you approved:
1. Schedule your consultation
The first step is a virtual or in-person visit with our Oklahoma-based medical team. We will review your medical history, current BMI, and any weight-related conditions (like hypertension or sleep apnea) to ensure you meet TRICARE’s clinical guidelines.
2. Documenting your journey
TRICARE requires extensive documentation before it pays for Zepbound. We help you compile the necessary records, including:
- Lifestyle efforts: Proof of at least six months of a supervised diet and exercise program.
- Step therapy history: Documentation showing you have tried or have medical reasons to avoid TRICARE’s preferred weight-loss drugs, such as phentermine.
- Lab results: We can provide at-home lab tests or review your recent blood work to strengthen your case.
3. Prior authorization (PA) submission
This is where NP2GO makes the difference. We understand the specific insurance language required by TRICARE and other insurance companies. Our providers fill out and submit the prior authorization and medical necessity forms on your behalf, ensuring all clinical criteria are highlighted to increase your chances of a first-time approval.
4. Request approval
It may take a few days or more to receive the decision. We will notify you when we hear from the insurance company regarding an acceptance or denial. If you’re approved, your weight-loss treatment can begin. We will help you coordinate your prescription through a military pharmacy or through TRICARE Pharmacy Home Delivery.
If you’re denied Zepbound coverage, we will review the decision and follow up with the insurance company.
FAQs About Tricare Coverage for Zepbound
What if Tricare won’t cover Zepbound?
If Tricare denies coverage for Zepbound, we may recommend alternative medications that may be more affordable. If you can’t find an option that fits your condition and budget, we may still help you request a 90-day prescription. A 3-month supply can be more cost-effective than filling monthly.
Can I use Tricare for Zepbound if I have other health insurance?
If you have additional health insurance, Zepbound will be primarily paid for by Tricare. Your other insurance can cover any remaining expenses after Tricare’s coverage.
Does Tricare limit the duration of Zepbound treatment?
Tricare does not limit the duration of Zepbound treatment. However, depending on your specific needs, we will advise you on how long it will take to receive your treatment.
How can I increase my chances of being approved for Zepbound by Tricare?
To increase your chances of approval, ensure you complete your health history questionnaire honestly.
Bring a copy of any documentation of your past attempts at weight loss, whether by diet, exercise, or medical supervision. We will review it and scan it into your chart. Examples of this type of material include diaries, personal records, medical chart notes, and receipts.
You may also get copies of your weight-loss treatment report if you have already taken treatment to show that you have been following up and adhering to any recommendations your prior practitioner gave.
Oklahoma Weight Loss and Weight Management Clinic
NP2GO Weight Loss Clinic is a leading Oklahoma weight loss clinic providing virtual care to TRICARE beneficiaries. Whether you are stationed at Tinker Air Force Base, Fort Sill, or Altus AFB, our nurse practitioners are licensed to provide the specialized care and insurance advocacy you need.
We are committed to providing the best weight management options, from virtual care visits to at-home lab tests. With our weight care solutions, NP2GO’s clinical care team helps identify the right medication for you based on your insurance coverage and health needs.
Remember that losing weight is more than just cosmetic. It can also be life-saving. If you want to learn more about Tricare coverage for Zepbound and how it can help manage your weight, book an appointment with us. You can also call 405-696-7003.
Our team of registered nurse practitioners will give you the required insight and guidance you need as you explore your alternatives and make informed decisions about your weight management.