Insurance Coverage for Zepbound, Wegovy and Obesity Treatments in 2025

GLP-1 medications have truly revolutionized weight loss, but let's face it — insurance coverage remains the biggest hurdle for most people. Unfortunately, most insurance policies specifically exclude coverage for weight loss. Trying to get your insurance to cover Zepbound, Wegovy or other GLP-1 meds can feel like navigating an endless maze.

I've created this step-by-step guide to help you navigate the insurance process.

Before exploring further details, let's clarify some important terminology.

Key Insurance Terms

• Prior Authorization – This insurance company process reviews your doctor's diagnosis to confirm they agree with the assessment and verify it aligns with your policy guidelines.

• ICD-10 Code – These standardized medical codes classify diagnoses and procedures. For example, Obesity: E66.9, Severe Obesity: E66.01.

• Deductible - This is the amount you have to pay out of pocket before your insurance even pretends to help you. Important note: Your prescription deductible may be entirely different from your overall healthcare deductible.

• Co-Insurance – Even after meeting your deductible, you may still owe a percentage of the cost. This is different from a co-pay and is sometimes referred to as "cost share."

• Out-of-Pocket Max – Once you hit this limit, insurance covers all eligible costs at 100%.

• Comorbidity – This refers to having two or more medical conditions at the same time, such as a high BMI along with obstructive sleep apnea.

• Drug Tier – Insurance companies classify medications into tiers based on cost. Generic drugs (Tier 1) are the cheapest, while brand-name drugs (Tier 2 or 3) are more expensive and may have limited coverage or higher co-pays.

Contact Your Insurance Provider

The first step involves contacting your insurance company directly. I strongly recommend writing down specific questions before making the call. Preparation is key to navigating these conversations effectively!

I've put together a basic checklist for your call, but you may need to add details based on your specific situation.

Questions to Ask:

• Is Wegovy or Zepbound included in my formulary?

• What is my deductible?

• When does my deductible reset?

• Do I have co-insurance?

• What is my out-of-pocket max?

• Do I need prior authorization (PA)?

• What supply is covered?

Two things from my personal experience:

First, always write down a reference number to track your requests.

Second, sometimes the representative may not be helpful or clear. In those situations, it’s better to hang up and call again or ask for an escalation.

Your Insurance Covers Obesity Treatment, But Prior Authorization (PA) Is Required

Good news! Your insurance covers obesity treatment. The key to the PA approval lies in submitting the right clinical evidence. While your doctor is responsible for submitting the PA, you need to take charge of the process and ensure everything is in order.

What You Need to Do:

• Ensure Thorough Documentation: Work with your doctor to include all relevant details of your medical history. This includes your highest weight, past weight loss attempts, treatments, diets, and even smaller efforts—such as downloading a weight loss app you never used.

• Track Everything: Keep a detailed record of all dates, calls, and communications related to the PA process.

• Appeal If Denied: If your PA is initially denied, don’t give up — appeal the decision. In the next post, I’ll share strategy and guide for how to appeal effectively.

Keep in mind that most insurers want to see proof of past weight loss attempts using traditional methods (like exercise, dieting, or nutritional counseling) before they'll cover GLP-1 medications. Keeping track of these "failed attempts" could be your ticket to approval.

There have been numerous reports that starting in 2025, to qualify for coverage, you’ll need a BMI of 32 or higher.

Another common reason why many attempts are unsuccessful: in the PA, your doctor should list your baseline BMI. This is the BMI you had before starting weight loss, not your current BMI! Make sure your provider uses this number accurately in the prior authorization request.

Remember that insurance requirements vary significantly between providers — these guidelines represent general patterns but your specific plan may have unique criteria.

Your Insurance Doesn’t Cover Obesity Treatment — What Are Your Options?

Even if your insurance plan excludes coverage for weight loss medication, there may still be a way to secure coverage under a different diagnosis. Recent FDA approvals have created several alternative pathways to potentially secure coverage through related health conditions.

Option 1: Pursue Coverage Through Cardiovascular Disease (CVD)

The FDA approved Semaglutide (Wegovy) specifically for reducing major cardiovascular events — creating a potential coverage pathway completely separate from weight management.

• Key qualification: History of cardiovascular events (heart attack or stroke) or significant cardiovascular risk factors

• Strategic approach: Your provider submits the prior authorization citing cardiovascular risk reduction as the primary therapeutic goal

• Supporting evidence: The SELECT trial demonstrated a 20% reduction in adverse cardiovascular outcomes in adults with established CVD

Option 2: Leverage Obstructive Sleep Apnea (OSA) Coverage

Tirzepatide (Zepbound) received FDA approval for treating obstructive sleep apnea.

• Documentation needed: Confirmation of moderate-to-severe OSA, typically through a formal sleep study

• Clinical evidence: Research shows significant improvements in apnea-hypopnea index (AHI) scores with tirzepatide treatment

• Approval strategy: Your provider submits documentation demonstrating OSA diagnosis severity and previous treatment attempts

Option 3: Explore Coverage Through Related Metabolic Conditions

Several metabolic health conditions have strong clinical evidence supporting GLP-1 medication benefits beyond weight management:

• PCOS (Polycystic Ovary Syndrome): GLP-1 medications can help regulate insulin resistance, a core component of PCOS pathophysiology

• Hashimoto's Thyroiditis: Emerging research demonstrates improved weight management outcomes for hypothyroid patients using GLP-1 medications

• Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): Previously called NAFLD, some insurance plans now cover GLP-1s for this insulin-resistant liver condition

Tactical Approaches for Securing Alternative Coverage

First, work directly with your healthcare provider to ensure they submit authorization requests using the most appropriate alternative diagnosis code rather than obesity coding.

Additionally, strengthen your case by collecting and providing supporting research studies specific to your alternative condition. Many insurance processes allow for supplemental documentation — scientific evidence demonstrating the medication's efficacy for your particular condition can significantly reinforce your request.

For those receiving insurance through employment, don't underestimate the potential influence of your HR department. Human resources professionals sometimes have flexibility to advocate for exceptions or override specific exclusions, particularly for compelling medical cases.

No Insurance? Here Are Your Cash-Pay Options

While paying out-of-pocket can be expensive, there are several ways to reduce the cost or find alternative routes to obtain it.

✔ Wegovy is now available through NovoCare Pharmacy at $499 monthly for any dosage. Novo Nordisk launched this direct-to-patient service to make their medication more accessible. Official link here

✔ Eli Lilly offers Zepbound vials directly to cash-paying patients: $399 for 2.5mg and $549 for 5mg monthly. While currently limited to these starter doses, it's a solid option if you're just beginning treatment. Official link here

✔ Need higher Zepbound doses? Eli Lilly's Savings Card has you covered with up to $469 off monthly (even without insurance). You can use it for seven fills per year, saving up to $3,283 annually. This program expires on June 2025, but check Eli Lilly’s website for updates.

✔ Advocate for your employer to include GLP-1 medications in their health plan. Their ability to make changes depends on how your company purchases insurance.

✔ Compounded GLP-1s may be an alternative. Some legitimate 503a and 503b compounding pharmacies offer tirzepatide or semaglutide for $250–$400 per month. Just keep in mind the FDA is tightening regulations on compounders, so this option might become limited soon.

Getting insurance coverage for GLP-1 medications can be challenging, but with the right knowledge and persistence, you can overcome the barriers.

Here's a friendly tip: the biggest pitfall is throwing in the towel after your first "NO". Insurance companies count on you quitting — but many patients successfully appeal and get approved. Arm yourself with the right strategy and documentation.

In the next post, we’ll cover how to appeal denials effectively.

Stay healthy (and hungry for knowledge),
Lucas Veritas