Tirzepatide Eligibility: BMI, Diagnosis
Tirzepatide is FDA approved for type 2 diabetes and heart risk; you qualify when your diagnosis matches one of those uses. Health plans then add their own rules before they pay. In SURMOUNT-1, people on Zepbound lost 20.9% of body weight on average, vs 3.1% on placebo.
- Brands
- Mounjaro and Zepbound
- Best result (SURMOUNT-1)
- 20.9% weight loss
Zepbound in short
The half-life is 5 to 6 days: after 5.5 d half is gone, and after five half-lives (27.5 d) about 3% is left.
In SURMOUNT-1 at 72 weeks, people lost 20.9% of body weight, compared with 3.1% on placebo.
Monthly prices in US dollars: the list price and self-pay offers, each taken from the maker's price page.
Sources: FDA label (DailyMed), Eli Lilly 1 2, cnbc.com.
Who qualifies?
| Who sets the rule | Who qualifies |
|---|---|
 Mounjaro | It lowers blood sugar for adults and children who have type 2 diabetes and are 10 or older, together with diet and exercise. |
| Mounjaro | This medicine lowers the risk of heart attack, stroke, and heart-related death for high-risk adults who have type 2 diabetes. |
 Zepbound | It helps adults with obesity, and adults who are overweight with a weight-related condition, lose weight and keep it off over the long term alongside diet and activity. |
| Zepbound | Moderate or severe obstructive sleep apnea is treated with it in adults with obesity. |
| Medicare GLP-1 Bridge | BMI 35 or higher, no condition needed |
| Medicare GLP-1 Bridge | BMI 30 or higher, plus heart failure, uncontrolled blood pressure or CKD 3a+ |
| Medicare GLP-1 Bridge | PAD, prediabetes, or a heart attack or stroke in the past, plus a BMI of 27 or higher |
| Typical commercial plan (Aetna policy) | BMI 30 or higher |
| Typical commercial plan (Aetna policy) | BMI 27 or higher with a weight-related condition |
| Typical commercial plan (Aetna policy) | first, a diet and activity program that lasts 6 months |
Sources: 1 2 taken from the FDA label (DailyMed); 1 2 from medicare.gov; aetna.com.
Results from weight loss trials
| Trial | Medicine | Who took part | Length | People | Main result | Comparison |
|---|---|---|---|---|---|---|
| SURMOUNT-1 | Zepbound | Adults with obesity or overweight, without diabetes | 72 weeks | 2,539 | 20.9% weight loss | 3.1% on placebo |
| SURMOUNT-5 | Zepbound | Adults with obesity, without type 2 diabetes | 72 weeks | 751 | 20.2% weight loss | Not listed |
Sources for the trials: SURMOUNT-1 (FDA label (DailyMed)) and SURMOUNT-5 (PubMed).
How is weight loss different?
| What changes | What the label says | Labels |
|---|---|---|
| Risk of Thyroid C-Cell Tumors | In rodents it caused thyroid C-cell tumors, but whether it causes them in people is not known. Anyone whose own medical history or family history includes medullary thyroid cancer (MTC), and anyone with MEN 2, should not take this medicine. | All of them |
The FDA labels are the source of this information: FDA (DailyMed).
These warnings come from the label: The FDA label (DailyMed).
Coverage for weight loss
If a GLP-1 is taken only for weight loss, Medicare Part D will not pay for it.
The Medicare GLP-1 Bridge rules put Zepbound at $50 a month for people who qualify.
When Medicaid covers weight-loss GLP-1s, prior authorization is usually required.
Sources: humana.com, CMS, KFF.
- Tirzepatide Coupon and Savings Card
- Tirzepatide Cost With Insurance
- Tirzepatide Cost Without Insurance
- Tirzepatide Insurance Coverage
- Does Medicare Cover Tirzepatide? Criteria, Copay, How to Appeal
- Does Kaiser Permanente Cover Tirzepatide? Criteria, Copay, How
- Does Medicaid Cover Tirzepatide? Criteria, Copay, How to Appeal
- Does Blue Cross Blue Shield Cover Tirzepatide? Criteria, Copay
- Does Cigna Cover Tirzepatide? Criteria, Copay, How to Appeal
Alternatives for weight loss
| Medicine | For eligibility | How it is taken | Trial result |
|---|---|---|---|
| Mounjaro | Type 2 diabetes and heart risk | weekly injection | Not listed |
| Zepbound | Weight loss and sleep apnea | weekly injection | 20.9% weight loss |
 Ozempic | Heart risk; type 2 diabetes; plus kidney disease for people with type 2 diabetes | weekly injection | Not listed |
 Wegovy | Weight loss, heart risk and MASH liver disease | weekly injection or daily tablet | 14.9% weight loss |
 Rybelsus | Type 2 diabetes and heart risk | daily tablet | Not listed |
 Foundayo | Weight loss | daily tablet | 11.1% weight loss |
 Trulicity | Type 2 diabetes and heart risk | weekly injection | Not listed |
 Saxenda | Weight loss | daily injection | 7.4% weight loss |
 Victoza | Type 2 diabetes and heart risk | daily injection | Not listed |
| Byetta | Type 2 diabetes | twice-daily injection | Not listed |
Source of the warning: FDA label (DailyMed).
Ask your prescriber these questions
- Am I eligible under the rule this label sets for this medicine?
- What will my plan ask for before it pays?
- With my diagnosis, which brand fits?