How to get prior authorization for Zepbound — a step-by-step guide

Zepbound (tirzepatide) is a prescription weight loss injection. It was approved by the U.S. Food and Drug Administration (FDA) in December 2023 for use in adults with obesity, or overweight with a weight-related medical problem. Since then, it’s gotten more popular as people taking Zepbound, with a reduced-calorie diet and increased physical activity, lose weight. Your health insurance plan may require prior authorization before covering Zepbound for you. In this article, we cover everything you need to know about how to get prior authorization for Zepbound. 

Understanding prior authorization

Prior authorization (PA) is a process insurance companies use to ensure a prescribed treatment is medically necessary. It requires your healthcare provider to submit paperwork to your insurance company to justify your use of the medication. A well-designed prior authorization process ensures that prescription drugs are used as intended. Prior authorization can also help insurance companies manage costs by requiring you to try a lower-cost alternative before approving a more expensive option. 

Why you need a prior authorization for Zepbound (tirzepatide)

Prior authorization for Zepbound helps insurance companies determine whether it’s medically necessary for the patient. You only need prior authorization for Zepbound if your insurance covers Zepbound and you want to reduce your out-of-pocket cost. Call the customer service number on the back of your insurance card to find out if your provider covers Zepbound.

How to get a prior authorization for Zepbound

Step 1: Find a provider to assess your weight loss needs

The first step to getting prior authorization (PA) for Zepbound is finding a healthcare provider who assesses your weight and health and determines you need Zepbound for weight loss. Schedule an appointment with your current provider or find a weight loss provider online using a marketplace service like Klarity. 

During your appointment, your provider will determine whether Zepbound is right for you. It’s approved for use in adults with a body mass index (BMI) of 30 or greater, or 27 or greater with a weight-related health condition. Zepbound should be used as part of a medical weight loss program that includes a reduced-calorie diet and increased physical activity. 

If you meet the criteria for taking Zepbound, your provider will give you a prescription. Ask your provider or call your insurance company to determine whether prior authorization is needed.

Step 2: Have your provider submit a prior authorization to your insurance company

The second step to getting prior authorization for Zepbound is to have your provider submit a request to your insurance company. Your provider’s office likely has a process in place for submitting PA requests. Tell your provider if you have any questions or concerns. 

Step 3: Don’t wait for a decision, follow up

The next step in the prior authorization process for Zepbound is to follow up with your insurance company. Prior authorization approvals can take anywhere from minutes to several days or weeks. Call your insurance company to check the status of your approval. 

Step 4: If your authorization is approved, start on Zepbound

If your prior authorization for Zepbound is approved, you can start your medication. Submit your prescription to your pharmacy of choice and pick it up once it’s filled or wait for it to be delivered of you ordered online or chose delivery. 

What to do if your prior authorization for Zepbound is denied

In 2023, KFF (formerly Kaiser Family Foundation) published a survey of adults with health insurance. They found that 19% of adults taking a prescription medication have problems with prior authorizations, including denials. 

And Zepbound reviews show that users do get prior authorization denials. In this section, we discuss reasons for prior authorization denials and what to do if you get denied. 

Reasons prior authorizations for Zepbound are denied

Prior authorization for Zepbound may be denied for different reasons. The most common reasons for PA denials include:

Zepbound isn’t covered

It could be that Zepbound isn’t covered by your plan after all. Some insurance companies deny prior authorization for Zepbound because it’s a new drug. In their opinion, there isn’t enough after-market research to justify the costs and risks associated with using it.

Cost management

Insurance companies conserve funds to save money while helping as many patients as possible get the medications they need. This includes denying pricier drugs in favor of lower-cost alternatives. Sitting on the high side, Zepbound costs around $1,126 per month. 

Questions about medical necessity

Your insurance company may question whether Zepbound is medically necessary for you. Some insurers deny coverage of prescription weight loss drugs for weight management if you don’t have another medical issue, like type 2 diabetes, or your BMI isn’t in the approved range. 

Administrative or procedural errors

Prior authorization could be denied if there’s a problem with the paperwork your healthcare provider submitted. Potential issues include:

• Clerical errors (for example, misspelled names or incorrect billing codes)
• Missing clinical information
• Lacking test results required by insurance

Patient hasn’t tried cheaper options

You may be denied prior authorization for Zepbound if you haven’t tried a less expensive alternative. Insurance plans often require patients to try and fail with other medicines before they approve a more expensive or newer option. 

Options to fight prior authorization denials for Zepbound

If your prior authorization for Zepbound is denied, call your insurance company to find out why. It’s possible they need more information and your denial could be easily overturned. If this isn’t the case, submit an appeal. Your healthcare provider can also appeal on your behalf. Health insurance plans are required to tell you the reason for denial. They should also let your provider talk to the reviewer about the denial.

Most states have 3 levels of appeals which include:

• First-level appeals — the first step in the process involves a phone call to your insurance company. Either you or your healthcare provider can call. Ask them to reconsider the denial on the grounds that your request was wrongly rejected. Your healthcare provider may need to provide additional information as evidence.
• Second-level appeals — in this step, the appeal is reviewed by a medical director at your insurance company. This person shouldn’t be involved in the original decision. The goal is to prove your request should be accepted within coverage guidelines.
• Independent external review — this is the final level of appeal. An independent reviewer with your insurance company and a medical doctor will assess your request. They then approve or deny coverage based on medical necessity.

If prior authorization for Zepbound is denied because you haven’t tried a cheaper alternative, you might submit a new request. Contact your insurance company for a list of covered Zepbound alternatives, such as other GLP-1 agonist medications. 

Together, you and your healthcare provider can choose the best weight loss medication for you. 

Be sure to document your experience. If you fail with another medication, you can submit a new PA for Zepbound.

What if your appeal fails

You can still use Zepbound if your appeal for prior authorization fails. But, you’ll most likely have to pay the full out-of-pocket cost for Zepbound. Valid coupons and discounts that don’t require insurance coverage can help you save money. And you may also be eligible to get Zepbound for $25 a month with the Zepbound Savings Card. 

Key takeaway

Zepbound (tirzepatide) is a popular weight loss medication. Prior authorization (PA) is typically required for insurance to cover it. This is a process insurance companies use to determine whether a medication is medically necessary. If approved, your plan’s drug copay applies to your Zepbound prescription.

To get prior authorization for Zepbound, you need a valid prescription from a licensed healthcare provider. Your provider will submit a prior authorization request. Decisions can happen in minutes or take several days or weeks. 

Prior authorization for Zepbound can be denied for many reasons. If your request is denied,  you have the right to appeal. You can appeal yourself or ask your provider to appeal for you. 

There are typically 3 levels of appeals — 2 reviews by your insurance company and 1 external review. You can still take Zepbound for weight loss if your appeal for prior authorization is denied, but you’ll have to find other ways to reduce your out-of-pocket costs. Coupons and discount cards may help you save.

Navigate weight loss with a provider on Klarity

Weight loss is easy to navigate with the right provider. Find a licensed healthcare provider specialized in weight loss on Klarity. Your provider can help you develop a medical weight loss plan that includes a medication, such as Zepbound. Get started and find a provider on Klarity today. 

Sources

Academy of Managed Care Pharmacy, Prior Authorization, Jul. 2019, https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/prior-authorization

Accreditation Council for Medical Affairs, What is Prior Authorization?, Amanda DeMarco, Dec. 2020, https://www.priorauthtraining.org/prior-authorization/

American Academy of Family Physicians, Precertification, Denials, and Appeals: Reducing the Hassles, Anthony N. Akosa, MD, MBA, Jun. 2006, https://www.aafp.org/pubs/fpm/issues/2006/0600/p45.html 

CoverMyMeds, 7 Common Prior Authorization Hurdles and How to Overcome Them, Miranda Delatore, MSN, RN, NEA-BC, Mar. 2022, https://insights.covermymeds.com/healthcare-technology/prior-authorization/common-prior-authorization-hurdles-and-how-to-overcome-them 

Drugs.com, Zepbound Prices, Coupons, and Patient Assistance Programs, https://www.drugs.com/price-guide/zepbound 

Eli Lilly, Prior Authorization and Pharmacy Information Guide – Zepbound, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://zepbound.lilly.com/assets/pdf/zepbound_Prior_Authorization_Resource_Guide.pdf 

Eli Lilly, Zepbound Pharmacy Stocking Guide, https://zepbound.lilly.com/assets/pdf/zepbound_Pharmacy_Stocking_Guide.pdf

JDRF Foundation, Denials and Appeals: What to do When Your Insurance Company Denies You Coverage, https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/insurance-denials-appeals/

Journal of Managed Care and Specialty Pharmacy, Caroline Forrester, PharmD, Jul. 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10391030/

KFF, Consumer Problems with Prior Authorization: Evidence from KFF Survey, Karen Pollitz, et al., Sept. 2023, https://www.kff.org/affordable-care-act/issue-brief/consumer-problems-with-prior-authorization-evidence-from-kff-survey/

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The information provided in this article is for educational purposes only and should not be construed as medical advice. Always seek the guidance of a qualified healthcare professional with any questions or concerns you have regarding your health.

How we reviewed this article: This article goes through rigorous fact-checking by a team of medical reviewers. Reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the author.