Tirzepatide Insurance Coverage: Zepbound vs Mounjaro PA Rules

Does insurance cover tirzepatide?

tirzepatide coverage by plan

Plan	For weight loss	For type 2 diabetes	Prior authorization
Medicare	Bridge program only	Covered by Part D plans	Required
Medicaid	Varies by state	Covered	Required
Cigna (Evernorth / Express Scripts)	Plan dependent	Covered on formulary	Required
Blue Cross Blue Shield	Plan dependent	Covered on formulary	Required
Kaiser Permanente	Plan dependent	Covered on formulary	Required
Aetna	Employer option	Covered on formulary	Required
UnitedHealthcare (Optum Rx)	Plan dependent	Covered on formulary	Required
CVS Caremark	Plan sponsor choice	Covered on formulary	Required
Express Scripts	Plan sponsor choice	Covered on formulary	Required
Optum Rx	Plan sponsor choice	Covered on formulary	Required
Humana	Bridge program only	Covered by Part D plans	Required
TRICARE	Prime and Select only	Covered with PA	Required
VA (Veterans Health Administration)	Covered with criteria	Covered	Required
GEHA	Covered with PA	Covered	Required
Ambetter (Centene)	Excluded	Covered on formulary	Required
ACA Marketplace plans	Rare	Common	Required
Navitus	Plan sponsor choice	Covered on formulary	Not listed
Amerigroup (Elevance Medicaid)	Follows state Medicaid	Covered with PA	Required

The published policy

• Medicare: The Bridge drug list includes Foundayo and Wegovy, Zepbound KwikPen
• CVS Caremark, Zepbound: It left the template formulary on July 1, 2025
• For CVS Caremark, Zepbound, October 1, 2026 marked its return as a preferred option
• Express Scripts, Excluded: No weight-loss coverage applies to Zepbound KwikPens or vials
• Medicare exclusions under Not in the Bridge apply to vials and single-dose pens
• Cigna add-on with a Copay cap of $200 each month (employer add-on)
• Unless an employer retained coverage, it was dropped in 2026 for Blue Cross Blue Shield, Blue Cross Massachusetts
• Weight-loss coverage: Optum Rx, CHAMPVA, Not covered

Sources: humana.com, medicare.gov, CMS, aetna.com.

A checklist for prior authorization

Weight-loss prior authorization rules by plan

Plan	Weight rule	Lifestyle program	To keep coverage
Aetna	The baseline is BMI 30 or higher, or BMI 27 or higher with a weight-related condition	6 months of a weight program first	5% of baseline weight lost to renew
Cigna (Evernorth / Express Scripts)	BMI 27 or higher with a weight-related condition	Not listed	5% weight loss after 3 months
UnitedHealthcare (Optum Rx)	BMI 27 or higher with a weight-related condition	Not listed	Not listed
Blue Cross Blue Shield	With BMI 35 or above, a weight-related condition is required (Horizon NJ)	Not listed	Not listed
VA (Veterans Health Administration)	BMI 27 or higher with a weight-related condition	Not listed	Not listed
Ambetter (Centene)	BMI 27 or higher with established heart disease	Not listed	Not listed

• Your height and weight, as measured, plus the BMI calculated from them.
• Conditions in your record that relate to weight, such as high cholesterol and also high blood pressure.
• A record of notes covering the diet and activity program that you tried.

Sources: aetna.com, static.cigna.com, uhcprovider.com, horizonblue.com.

The appeal, if you are denied

1. Get the denial letter, which identifies the exact rule that was not met.
2. With the appeal, your prescriber sends chart notes that address the rule.
3. If the plan's appeal fails, ask for an external review by an independent reviewer.

Differences between states and plans

One state or employer plan from the same insurer may cover you while another does not.

• Unless an employer retained coverage, it was dropped in 2026 for Blue Cross Blue Shield, Blue Cross Massachusetts
• The exclusion described here has no appeal option: Blue Cross Blue Shield, Appeal: No appeal
• Blue Cross Blue Shield, Horizon (New Jersey) weight rule: With BMI 35 or above, a weight-related condition is required (Horizon NJ)
• In New Jersey, the Blue Cross Blue Shield, Horizon rule takes effect January 1, 2026
• For Blue Cross Blue Shield, Federal Employee Program, the policy date is October 1, 2026
• Kaiser Permanente, When coverage applies: whether you are covered depends on the benefit
• A cash price applies to Kaiser Permanente, Members without the benefit
• For Type 2 diabetes treatment, TRICARE coverage requires PA

Each state sets its own Medicaid rules. GLP-1s for weight loss have coverage now in 10 states: Delaware, Kansas, Michigan, Minnesota, Mississippi, Missouri, North Carolina, Tennessee, Virginia and Wisconsin. Compare every state side by side.

Sources: bluecrossma.org, horizonblue.com, info.caremark.com, healthy.kaiserpermanente.org.

Other choices if coverage says no

If coverage says no

Medicine	Lowest self-pay	Manufacturer options when your plan offers no coverage
Mounjaro	Not listed	$499 a month
Zepbound	$299 a month	$299 a month

Sources: pricinginfo.lilly.com, mounjaro.lilly.com, GoodRx, zepbound.lilly.com.