<p>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.&nbsp;</p><div class="wp-block-klarity-cta-banner-section-v3 k-cmp k-section cmp-cta-banner-section cmp-layout--r-img cmp-background--sky-mist cmp-img-type--image cmp-img-mode--cover cmp-img-effect--none" style="--cmp-background-color:#e5f3fe" data-layout="r-img"><div class="k-section-inner"><div class="k-row"><div class="k-col"><h2 class="k-headline">Start your weight loss journey in 24 hours or less*</h2><div class="k-desc"><p></p></div><a class="k-cta k-cta--button" href=https://www.helloklarity.com/condition/weight-loss target="_blank">Find a provider</a></div><div class="k-col"><figure class="k-img-wrapper"><img decoding="async" class="k-img" src="https://cms.helloklarity.com/wp-content/uploads/2024/05/Prior-authorization-for-Zepbound.jpg" alt="Woman smiling and giving thumbs up" title=""></figure></div></div></div></div><h2 class= "subtitle" id='heading_2_Understanding_prior_authorization'>Understanding prior authorization</h2><p>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.&nbsp;</p><h2 class= "subtitle" id='heading_2_Why_you_need_a_prior_authorization_for_Zepbound_(tirzepatide)'>Why you need a prior authorization for Zepbound (tirzepatide)</h2><p>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 <a href=https://www.helloklarity.com/post/is-zepbound-covered-by-insurance/ target="_blank">insurance covers Zepbound</a> 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.</p><h2 class= "subtitle" id='heading_2_How_to_get_a_prior_authorization_for_Zepbound'>How to get a prior authorization for Zepbound</h2><h3 class="wp-block-heading">Step 1: Find a provider to assess your weight loss needs</h3><p>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 <a href=https://www.helloklarity.com/condition/weight-loss target="_blank">find a weight loss provider</a> online using a marketplace service like Klarity Health. </p><p>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 <a href=https://www.helloklarity.com/post/medical-weight-loss-programs/ target="_blank">medical weight loss program</a> that includes a reduced-calorie diet and increased physical activity.&nbsp;</p><p>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.</p><h3 class="wp-block-heading">Step 2: Have your provider submit a prior authorization to your insurance company</h3><p>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.&nbsp;</p><h3 class="wp-block-heading">Step 3: Don’t wait for a decision, follow up</h3><p>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.&nbsp;</p><h3 class="wp-block-heading">Step 4: If your authorization is approved, start on Zepbound</h3><p>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&nbsp;of you ordered online or chose delivery.&nbsp;</p><h2 class= "subtitle" id='heading_2_What_to_do_if_your_prior_authorization_for_Zepbound_is_denied'>What to do if your prior authorization for Zepbound is denied</h2><p>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.&nbsp;</p><p>And <a href=https://www.helloklarity.com/post/zepbound-reviews/ target="_blank">Zepbound reviews</a> 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.&nbsp;</p><h3 class="wp-block-heading">Reasons prior authorizations for Zepbound are denied</h3><p>Prior authorization for Zepbound may be denied for different reasons. The most common reasons for PA denials include:</p><h4 class="wp-block-heading">Zepbound isn’t covered</h4><p>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.</p><h4 class="wp-block-heading">Cost management</h4><p>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, <a href=https://www.helloklarity.com/post/zepbound-cost/ target="_blank">Zepbound costs</a> around $1,126 per month.&nbsp;</p><h4 class="wp-block-heading">Questions about medical necessity</h4><p>Your insurance company may question whether Zepbound is medically necessary for you. Some insurers deny coverage of <a href=https://www.helloklarity.com/post/best-prescription-weight-loss-pills/ target="_blank">prescription weight loss</a> 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.&nbsp;</p><h4 class="wp-block-heading">Administrative or procedural errors</h4><p>Prior authorization could be denied if there’s a problem with the paperwork your healthcare provider submitted. Potential issues include:</p><ul><li>Clerical errors (for example, misspelled names or incorrect billing codes)</li><li>Missing clinical information</li><li>Lacking test results required by insurance</li></ul><h4 class="wp-block-heading">Patient hasn’t tried cheaper options</h4><p>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.&nbsp;</p><h3 class="wp-block-heading">Options to fight prior authorization denials for Zepbound</h3><p>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.</p><p>Most states have 3 levels of appeals which include:</p><ul><li><strong>First-level appeals </strong>— 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.</li><li><strong>Second-level appeals </strong>— 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.</li><li><strong>Independent external review </strong>— 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.</li></ul><p>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 <a href=https://www.helloklarity.com/post/glp-1-agonist-medications/ target="_blank">GLP-1 agonist medications</a>.&nbsp;</p><p>Together, you and your healthcare provider can choose the best weight loss medication for you.&nbsp;</p><p>Be sure to document your experience. If you fail with another medication, you can submit a new PA for Zepbound.</p><h3 class="wp-block-heading">What if your appeal fails</h3><p>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 <a href=https://www.helloklarity.com/post/how-to-get-Zepbound-for-25/ target="_blank">get Zepbound for $25</a> a month with the Zepbound Savings Card.&nbsp;</p><h2 class= "subtitle" id='heading_2_Key_takeaway'>Key takeaway</h2><p>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.</p><p>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.&nbsp;</p><p>Prior authorization for Zepbound can be denied for many reasons. If your request is denied,&nbsp; you have the right to appeal. You can appeal yourself or ask your provider to appeal for you.&nbsp;</p><p>There are typically 3 levels of appeals — 2 reviews by your insurance company and 1 external review. You can still take <a href=https://www.helloklarity.com/post/zepbound-for-weight-loss/ target="_blank">Zepbound for weight loss</a> 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.</p><h2 class= "subtitle" id='heading_2_Navigate_weight_loss_with_a_provider_on_Klarity_Health'>Navigate weight loss with a provider on Klarity Health</h2><p>Weight loss is easy to navigate with the right provider. Find a licensed healthcare provider specialized in weight loss on Klarity Health. Your provider can help you develop a medical weight loss plan that includes a medication, such as Zepbound. Get started and <a href=https://www.helloklarity.com/condition/weight-loss/ target="_blank">find a provider</a> on Klarity Health today. </p><div class="wp-block-klarity-faq-section k-cmp k-section cmp-faq-section cmp-layout--default cmp-style--undefined" data-layout="default"><div class="k-section-inner"><div class="k-section-head"></div><div class="k-section-content"><dl class="k-faq-list"><dt class="k-faq-q"><h3><strong>Sources</strong></h3></dt><dd class="k-faq-a"><p>Academy of Managed Care Pharmacy, Prior Authorization, Jul. 2019, <a href=https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/prior-authorization target="_blank" rel="noopener" target="_blank">https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/prior-authorization</a><br><br>Accreditation Council for Medical Affairs, What is Prior Authorization?, Amanda DeMarco, Dec. 2020, <a href=https://www.priorauthtraining.org/prior-authorization/ target="_blank" rel="noopener" target="_blank">https://www.priorauthtraining.org/prior-authorization/</a><br><br>American Academy of Family Physicians, Precertification, Denials, and Appeals: Reducing the Hassles, Anthony N. Akosa, MD, MBA, Jun. 2006, <a href=https://www.aafp.org/pubs/fpm/issues/2006/0600/p45.html target="_blank" rel="noopener" target="_blank">https://www.aafp.org/pubs/fpm/issues/2006/0600/p45.html</a> <br><br>CoverMyMeds, 7 Common Prior Authorization Hurdles and How to Overcome Them, Miranda Delatore, MSN, RN, NEA-BC, Mar. 2022, <a href=https://insights.covermymeds.com/healthcare-technology/prior-authorization/common-prior-authorization-hurdles-and-how-to-overcome-them target="_blank" rel="noopener" target="_blank">https://insights.covermymeds.com/healthcare-technology/prior-authorization/common-prior-authorization-hurdles-and-how-to-overcome-them</a> <br><br>Drugs.com, Zepbound Prices, Coupons, and Patient Assistance Programs, <a href=https://www.drugs.com/price-guide/zepbound target="_blank" rel="noopener" target="_blank">https://www.drugs.com/price-guide/zepbound</a> <br><br>Eli Lilly, Prior Authorization and Pharmacy Information Guide &#8211; Zepbound, chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/<a href=https://zepbound.lilly.com/assets/pdf/zepbound_Prior_Authorization_Resource_Guide.pdf target="_blank" rel="noopener" target="_blank">https://zepbound.lilly.com/assets/pdf/zepbound_Prior_Authorization_Resource_Guide.pdf</a> <br><br>Eli Lilly, Zepbound Pharmacy Stocking Guide, <a href=https://zepbound.lilly.com/assets/pdf/zepbound_Pharmacy_Stocking_Guide.pdf target="_blank" rel="noopener" target="_blank">https://zepbound.lilly.com/assets/pdf/zepbound_Pharmacy_Stocking_Guide.pdf</a><br><br>JDRF Foundation, Denials and Appeals: What to do When Your Insurance Company Denies You Coverage, <a href=https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/insurance-denials-appeals/ target="_blank" rel="noopener" target="_blank">https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/insurance-denials-appeals/</a><br><br>Journal of Managed Care and Specialty Pharmacy, Caroline Forrester, PharmD, Jul. 2020, <a href=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10391030/ target="_blank" rel="noopener" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10391030/</a><br><br>KFF, Consumer Problems with Prior Authorization: Evidence from KFF Survey, Karen Pollitz, et al., Sept. 2023, <a href=https://www.kff.org/affordable-care-act/issue-brief/consumer-problems-with-prior-authorization-evidence-from-kff-survey/ target="_blank" rel="noopener" target="_blank">https://www.kff.org/affordable-care-act/issue-brief/consumer-problems-with-prior-authorization-evidence-from-kff-survey/</a><br><br>Reddit, Zepbound PA Denials, <a href=https://www.reddit.com/r/Zepbound/comments/18aqnjv/zepbound_pa_denied/ target="_blank" rel="noopener" target="_blank">https://www.reddit.com/r/Zepbound/comments/18aqnjv/zepbound_pa_denied/</a></p></dd><dt class="k-faq-q"><h3>How we reviewed this article</h3></dt><dd class="k-faq-a"><p>This article went 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. Learn more about the <a href=https://www.helloklarity.com/policy/editorial-standards/ target="_blank">editorial and medical review</a> process and standards for the HelloKlarity site.</p></dd></dl></div></div></div><div class="wp-block-klarity-disclaimer-section k-cmp k-section cmp-disclaimer-section cmp-style--default" data-style="default"><div class="k-section-inner"><div class="k-section-content"><p>*Appointments are generally available within 24 hours. Free initial consultations are available only with select providers. Prescriptions, particularly for controlled substances, may require an in-person evaluation depending on the state of residence and current federal regulations.</p><p><br>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. Providers on Klarity Health are independent practitioners with clinical autonomy. Nothing in this article is intended to diagnose or treat any condition, including guaranteeing prescription medication of any kind or dosage.  Not all providers on Klarity Health prescribe all medications, particularly medications that are controlled substances.<br><br>If you’re having a mental health crisis or experiencing a psychiatric emergency, it’s crucial to seek immediate help from a mental healthcare professional, such as a psychiatrist, psychologist, or therapist. You can also call your local emergency services, visit your nearest emergency room, or contact a crisis hotline, such as the National Suicide Prevention Lifeline, by calling or texting 988 or dialing the Lifeline’s previous phone number, 1-800-273-TALK (1-800-273-8255) in the U.S.</p></div></div></div>

Dr. Sheelu Bhatnagar

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

Why you need a prior authorization for Zepbound (tirzepatide)

How to get a prior authorization for Zepbound

What to do if your prior authorization for Zepbound is denied

Navigate weight loss with a provider on Klarity Health