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 in order 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 you with all the information you need to know.
What Is Zepbound?
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-agonists such as Zepbound may slow stomach emptying, prolonging the time it takes for the body to absorb nutrients and help 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.
Does Tricare Cover Zepbound?
Tricare may cover Zepbound for weight management, but coverage may vary based on a specific plan and eligibility criteria. It’s important to inquire with Tricare directly or consult our healthcare professional at NP2GO to help determine your coverage options.
Tricare is a healthcare program available for military personnel, retirees, and their families. It offers coverage for several treatments and medical services.
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 a lifestyle change through exercise and diet for at least 6 months and to have tried and failed or have contraindications to qsymia, phentermine, and contrave.
- 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
Our healthcare provider will help fill out a Prior Authorization form and submit paperwork to Tricare to determine your eligibility for Zepbound. This will include documenting your height, weight, BMI, comorbid conditions, and attempts to lose weight through lifestyle changes and other weight-loss medications.
This step ensures that Tricare approves coverage of Zepbound for you. We understand the insurance language better than the average customer, so we may be more persuasive for your coverage.
We can also offer documentation like lab results, notes on your response to previous treatments, clinical guidelines, and more.
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 treatment for weight loss can begin.
If you’re denied Zepbound coverage, we will review the decision and follow up with the insurance company.
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. 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 on how long it takes to get your treatment.
How can I increase my chances of being approved by Tricare for Zepbound?
To increase your chances of approval, ensure you honestly complete your health history questionnaire.
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 among the most highly regarded weight management programs in the U.S. Our experts, who are among the most experienced in the field, believe that by offering several weight loss medication options—including Wegovy, Saxenda, Mounjaro, Zepbound, and Contrave—under one roof, we can best meet the specific needs of our patients.
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.