Zepbound offers a fresh approach for adults managing chronic weight issues. This injectable treatment from Eli Lilly uses tirzepatide to target hormones that control hunger and blood sugar. Paired with diet and exercise, it helps many achieve steady progress toward their goals.
Express Scripts manages pharmacy benefits for millions through employer plans, Medicare, and more. As part of Evernorth, it focuses on affordability and access via formularies that list covered drugs. Knowing how this works can clarify your options for medications like Zepbound.
This article dives into the details for 2025, including formulary status and steps to pursue coverage. It equips you with tools to check your benefits and explore alternatives if needed.
What Is Zepbound and How Does It Work?
Zepbound activates GLP-1 and GIP receptors in the body. These mimic natural signals that slow digestion and promote fullness, reducing overall calorie intake. Users often notice fewer cravings and better portion control.
Clinical data from trials show average weight loss of 15-21% over 72 weeks with lifestyle support. Doses start at 2.5 mg weekly, increasing gradually to minimize side effects like nausea. This titration helps most people adjust comfortably.
The FDA approved Zepbound in 2023 for obesity (BMI ≥30) or overweight (BMI ≥27) with conditions like hypertension. A 2024 expansion covers moderate-to-severe obstructive sleep apnea (OSA) in similar groups. This makes it versatile for related health concerns.
Side effects are mostly mild gastrointestinal issues that fade over time. Hydration and light meals ease them. Unlike single-agonist drugs, its dual action may yield stronger results for some.
Understanding Express Scripts Pharmacy Benefits
Express Scripts uses a National Preferred Formulary (NPF) to guide coverage. Drugs fall into tiers: Tier 1 generics are cheapest, while Tier 3 or specialty like Zepbound cost more. Plans customize this based on employer or insurer choices.
Pharmacy networks include major chains for retail fills and home delivery for 90-day supplies. This saves time and often money. Digital tools let members check coverage instantly.
Prior authorization (PA) applies to high-cost meds to confirm medical need. Express Scripts reviews via ePA systems for quick decisions. Wellness programs add support like coaching.
Medicare plans exclude weight loss drugs federally, limiting options there. Commercial plans vary widely by sponsor opt-ins.
Does Express Scripts Cover Zepbound?
Express Scripts includes Zepbound on its 2025 National Preferred Formulary as a preferred weight loss option, but coverage depends on your specific plan’s opt-in and prior authorization approval. Employer-sponsored plans often cover it with PA for eligible BMI and comorbidities, while Medicare excludes pure weight loss use. New programs like Patient Assurance cap copays at $200 monthly for participating plans.
Plans using EnGuide Pharmacy handle GLP-1 fills exclusively since mid-2025, streamlining delivery. Omada enrollment may be required for some to prove lifestyle commitment. Always verify via your portal, as exclusions apply if weight loss is deemed cosmetic.
Step 1: Verify Formulary Status and Plan Coverage
Log into express-scripts.com or call 1-800-282-2881 with your member ID. Search “Zepbound” or “tirzepatide” to see tier and PA notes. Download the 2025 NPF for your plan type.
If listed as preferred, note copay estimates. Non-coverage often ties to employer exclusions—contact HR if employer-sponsored. This step confirms basics in under 10 minutes.
Step 2: Confirm Eligibility with Your Doctor
Schedule a visit to document BMI ≥30 (or ≥27 with issues like diabetes) and failed prior attempts (e.g., diet programs). For OSA, include sleep study results.
Discuss comorbidities strengthening your case. Your provider prepares PA docs, including labs and history. This ensures medical necessity alignment.
Step 3: Submit Prior Authorization Request
Your doctor uses Express Scripts’ ePA via CoverMyMeds or faxes the form to 1-877-251-5896. Include diagnosis codes (e.g., E66.01), BMI proof, and step therapy evidence.
Reviews take 24-72 hours for ePA; track status online. Urgent needs qualify for faster processing. Incomplete submissions delay approval.
Step 4: Handle Approval, Denials, or Appeals
Approved PAs last 3-12 months; refill via home delivery for best rates. Denials cite ineligibility—appeal within 60 days with added evidence like updated weights.
Omada participation may resolve some issues. If denied, explore Lilly’s card for $550 off self-pay.
Eligibility Criteria for Coverage
Qualifiers need documented obesity or overweight with comorbidities. Plans require 3-6 months of failed conservative therapy. Exclusions: pregnancy, thyroid cancer history.
Omada enrollment verifies engagement for many plans in 2025. Dual diabetes use (as Mounjaro) eases PA. Keep records current.
The Prior Authorization Process
PA confirms necessity per NPF guidelines. Providers submit clinical rationale; Express Scripts approves if criteria met. ePA speeds 80% of cases.
Denials prompt appeals with peer-reviewed data. Timelines: standard 2 days, urgent 24 hours. Portal tracks progress.
Potential Costs and Copays
List price nears $1,060 monthly without coverage. Tier 3 placement means $100-300 copays post-deductible in commercial plans. Patient Assurance limits to $200 for opt-in plans.
Home delivery offers 90-day fills at lower effective rates. Deductibles $1,000-5,000 apply first.
| Plan Type | Tier/Status | Estimated Monthly Copay | Notes |
|---|---|---|---|
| Commercial (Opt-in) | Preferred Tier 3 | $100-$300 (post-deductible) | PA required; Omada may apply; $200 cap via Assurance |
| Employer w/ Wellness | Specialty | $25-$200 | Includes programs like EnGuide; 90-day preferred |
| Medicare Part D | Excluded for Weight Loss | Full price or N/A | OSA possible; diabetes as Mounjaro covered |
Use tools for personalized quotes.
Alternatives If Coverage Is Limited
Wegovy serves similar GLP-1 needs, often preferred alongside Zepbound. Mounjaro covers diabetes-related use.
Lifestyle via Express Scripts’ programs: free coaching, apps. Compounded tirzepatide fills gaps at $300-500, but verify quality.
OTC like orlistat aids mildly. Surgery for severe cases post-counseling.
Benefits of Zepbound Under Coverage
Covered access ensures steady supply via EnGuide. Weight loss reduces risks like diabetes by 20% in studies. Improved mobility, energy follow.
Maintenance prevents regain with habits. OSA users see better sleep.
Tips for Navigating Express Scripts
Enroll in alerts for formulary updates. Use app for refills, PA status.
Opt for 90-day home delivery to cut trips. Appeal denials promptly with doctor support.
Review during open enrollment for better tiers.
Integrating Zepbound with Lifestyle Changes
Emphasize proteins, veggies for satiety. Walk 30 minutes daily to amplify effects.
Track via Omada for compliance. Sleep 7-9 hours regulates hormones.
Common Challenges and Solutions
PA delays? Follow up weekly. Shortages? EnGuide prioritizes covered fills.
Nausea? Eat small meals. Cost spikes? Apply savings cards post-PA.
Summary
Express Scripts covers Zepbound on its 2025 formulary for opting-in plans with PA, focusing on medical necessity. Steps like eligibility checks and submissions unlock access, with caps easing costs. Alternatives and programs support if barriers arise. Verify your plan—proactive steps pave the way to sustained health.
FAQ
Does Express Scripts cover Zepbound for weight loss in 2025?
Zepbound is preferred on the NPF, but coverage requires plan opt-in and PA for BMI criteria. Employer plans vary; Medicare excludes. Check portal for your status.
What are the prior authorization requirements for Zepbound?
Doctor submits BMI proof, comorbidities, failed therapies via ePA. Omada enrollment often needed. Approvals in 1-2 days.
How much is the copay for Zepbound with Express Scripts?
$100-300 Tier 3 post-deductible; $200 cap via Patient Assurance for eligible. Varies by plan; home delivery lowers effective cost.
Why might Express Scripts deny Zepbound coverage?
Common reasons: no PA, ineligible BMI, or plan exclusion for weight loss. Appeal with more docs. Omada non-compliance factors in.
Can I use Lilly’s savings card with Express Scripts?
Yes, post-PA for commercial plans, reducing to $25-$550. Confirm at fill; some restrictions apply.