Zepbound Prior Authorization: Plan Criteria, Timelines and Appeals

Prior authorization is your plan's review before it will cover Zepbound: your prescriber sends records, and the plan checks them against its written criteria.^1, 2 For weight management, CVS Caremark, Express Scripts, Prime Therapeutics and FEP Blue all ask for a BMI of at least 30, or at least 27 with a weight-related condition. All four also want a diet and lifestyle program first: 3 to 6 months at Caremark, Express Scripts and Prime, with no set length at FEP Blue.^{3, 4, 5, 6} For sleep apnea, Caremark, Express Scripts and Prime want a sleep study showing moderate to severe sleep apnea, 15 or more breathing events an hour. They also want a BMI of 30 or more.^3, 4, 5

Federal rules give most employer and individual plans 15 days to decide (a plan can extend once, by 15 days) and Medicare drug plans 72 hours. Both are counted from the day the plan receives the request, and both are shorter when waiting could seriously harm your health.^{7, 8, 9, 10} First approvals last 6 to 12 months. To renew a weight-management approval, plans usually want at least 5% weight loss. Sleep apnea renewals look at how your symptoms respond, and Express Scripts also wants 10% weight loss after the first year.^{3, 4, 5, 6}

Since October 1, 2026, CVS Caremark has again listed Zepbound as a preferred option on select commercial formularies (lists of covered drugs). That applies to employers and other plan sponsors that choose to cover weight-loss drugs.^11, 1 If your plan excludes weight-loss drugs, prior authorization can't change that; the appeals section covers what you can still do.

• Turned down? Appeal steps for work, individual, federal employee and Medicare plans
• Waiting to hear? How long a decision takes
• Getting ready to file? Each plan's criteria, sleep apnea rules, whether your plan covers Zepbound at all and what goes in the request
• Already approved? Approval periods and renewals
• Starting Zepbound? The label warnings a prior authorization doesn't cover
• No coverage at all? Other ways to pay, and what to weigh

What Caremark, Express Scripts, Prime and FEP Blue ask for

CVS Caremark and Express Scripts manage prescription benefits for employers and health plans and publish the criteria their reviewers apply. Prime Therapeutics and FEP Blue, the Blue Cross Blue Shield plan for federal employees, publish theirs too.^{11, 12, 5, 6, 13} Your own plan can change the rules. CVS says plan sponsors keep discretion to customize coverage, and Prime warns that a plan may not cover every drug its document lists.^11, 5

The starting point is the FDA label. Zepbound is approved for two uses in adults, each in combination with a reduced-calorie diet and increased physical activity. One is losing excess weight and keeping it off, for people with obesity or people with overweight who have at least one weight-related condition. The other is treating adults with obesity who have moderate to severe obstructive sleep apnea; the label's warnings are further down this page.¹⁴

For weight management, all four set a BMI of at least 30, or at least 27 if you also have a weight-related condition. Typical conditions are high blood pressure, abnormal cholesterol or type 2 diabetes. Prime also accepts 25 or more for people of South, Southeast or East Asian descent, and FEP Blue counts established cardiovascular disease as a qualifying condition.^{3, 4, 5, 6} Where they differ:

Caremark and Prime describe the program as diet, physical activity and behavior change; Express Scripts asks for diet and behavior change.^3, 5, 4 FEP Blue counts a drug as ruled out if it didn't work, wasn't tolerated or isn't safe for you.⁶ Approval lengths and renewal rules are in the renewals section.

Which BMI counts. Caremark and Express Scripts use your BMI from before treatment. Express Scripts measures it before any GLP-1 drug, and Caremark tells reviewers to consider your BMI from when you began any weight-loss drug.^4, 3 Prime's and FEP Blue's documents give BMI thresholds without saying whether they mean before treatment or now.^5, 6 If you already take a GLP-1, ask your plan which it uses. On plans that use Evernorth's EncircleRx program, someone already taking a GLP-1 is judged by their BMI at the first coverage review.¹⁵

If you pay cash for Zepbound now, or take compounded tirzepatide (which is not FDA-approved; see below), keep dated weight records from before you started.¹⁶ Our page on changing from compounded tirzepatide to Zepbound covers that move.

EncircleRx plans set a higher bar: a BMI of at least 32, or at least 27 with two weight-related conditions. You must enroll in an Evernorth lifestyle program before the request can be completed. Evernorth defines the "active engagement" it expects as four weigh-ins and four app engagements a month. Prescribers can arrange an EncircleRx review by calling Express Scripts.¹⁵

Caremark plans that still prefer Wegovy. Where a Caremark formulary names Wegovy as the alternative, Caremark's tirzepatide exception approves Zepbound for 12 months. It does so only if Wegovy didn't work, caused side effects you couldn't tolerate, or isn't safe for you.¹⁷

No doubling up. Express Scripts, Prime and FEP Blue refuse Zepbound alongside another GLP-1 drug, and the Express Scripts and Prime documents name Mounjaro, which is also tirzepatide.^4, 5, 6 Mounjaro itself goes through diabetes criteria. Express Scripts' diabetes policy approves it for type 2 diabetes and lists weight loss among the uses it does not approve.¹⁸

Plans not in the table. Optum Rx's standard guidelines apply only to plans that use its standard drug lists, and prescribers can ask Optum Rx for one.¹⁹ UnitedHealthcare's rules are on our UnitedHealthcare page, and Anthem's on our Anthem page.

Sleep apnea has its own criteria

On a sleep study, the apnea-hypopnea index (AHI) is the number of apneas and hypopneas in an hour of sleep, as Express Scripts defines it. In the label's sleep apnea trials, moderate meant an AHI of 15 to 30 and severe meant 30 or more.^4, 14 Caremark, Express Scripts and Prime each have a separate sleep apnea section:

• CVS Caremark: an established diagnosis with an AHI of at least 15 on an in-lab sleep study or a home sleep apnea test, and a current BMI of 30 or more. It approves 6 months at first, then 12 months at a time if your symptoms have improved and you are on a maintenance dose.³
• Express Scripts: a sleep study diagnosing moderate to severe obstructive sleep apnea with an AHI of 15 or more, and a BMI of 30 or more before any GLP-1. It won't approve anyone with central sleep apnea, when the brain doesn't send the signals needed to breathe. Nor will it approve anyone with Cheyne-Stokes respiration, a breathing pattern that alternates deep, heavy breaths with shallow breathing or none, usually during sleep.^4, 20, 21 It approves 1 year at a time. After the first year, renewal needs at least 10% weight loss and stable symptoms, in your prescriber's judgment.⁴
• Prime Therapeutics: medical records of an in-lab or home sleep test with an AHI of 15 or more before treatment, and a BMI of 30 or more. Renewal, every 12 months, needs a clinical benefit, such as a lower AHI or a lower score on the Epworth Sleepiness Scale.⁵ The scale is a questionnaire that scores how likely you are to doze off in eight everyday situations.²²

FEP Blue's policy lists only chronic weight management and says Zepbound "may be considered investigational for all other indications."⁶ So FEP Blue members with sleep apnea should ask the plan how it reviews that use before the prescriber files.

This route can matter where weight-loss drugs are excluded. In Prime's document, the requirement that your benefit not exclude obesity appears in the weight-management sections, not the sleep apnea one.⁵ UnitedHealthcare says weight-loss drugs are typically a benefit exclusion, yet it runs a separate program that can cover Zepbound for sleep apnea with obesity. See UnitedHealthcare's sleep apnea route.²³ Medicare drug plans treat sleep apnea differently from weight loss; see the Medicare section.

The route needs a real diagnosis. Plans ask for records of the sleep study. So the route is open only when a sleep study shows moderate to severe sleep apnea (an AHI of 15 or more), never as a new label for a weight-loss request.^5, 3

If you use PAP (positive airway pressure, such as CPAP), keep using it unless your sleep clinician tells you otherwise. One of the label's sleep apnea trials enrolled people who were already using PAP. The label says the trials did not test when, or whether, people who used PAP regularly should stop.¹⁴

Does your plan cover Zepbound at all?

Criteria matter only if your plan covers Zepbound for your use. That is set by your plan, through your employer or insurer and, in some states, state coverage rules, not by your doctor.^11, 1, 24 Caremark lists drugs that are high in price among those that typically need prior authorization.²⁵

In KFF's 2025 employer survey, 19% of firms with 200 or more workers that offer health benefits covered GLP-1 drugs for weight loss, and 43% of firms with 5,000 or more did. Of the firms that covered them, 34% also required a dietitian, case manager, therapist or lifestyle program.²⁶

The form of Zepbound matters too. A KwikPen is a pen holding four weekly doses.¹⁴ Caremark's Zepbound criteria cover every form except vials, which they leave to Lilly's LillyDirect program, and its Wegovy-first exception also leaves out KwikPens.^3, 17 On Express Scripts' 2027 National Preferred Formulary, KwikPens and vials are excluded, and Zepbound single-dose pens are among the listed preferred alternatives.¹²

Express Scripts tells members that not every listed drug is covered by every plan and to call the number on their prescription ID card with coverage questions.¹² When you call or sign in, ask:

• Is Zepbound on my drug list, and in which form: single-dose pen, KwikPen or vial?¹
• Does it need prior authorization, and does my plan cover weight-loss drugs at all?¹
• Which company reviews the request, and where can my prescriber find its criteria?
• What would I pay for each fill once it's approved? An approval isn't a promise that the plan will cover the cost.²

How a request moves, and what goes in it

1. The prescription goes in. If the plan needs prior authorization, your prescriber's office submits the request.¹ At Caremark, for example, members are asked to have their prescriber contact its prior authorization department to answer the criteria questions.²⁵
2. The office sends the request. There is no single Zepbound form. Caremark takes requests electronically or by phone and posts a global prior authorization form.²⁵ Optum Rx takes electronic requests or calls to 1-800-711-4555.¹⁹ Express Scripts takes coverage-review requests at esrx.com/PA.¹² On a Medicare drug plan, you or your prescriber can also ask by sending Medicare's model coverage determination request form, writing a letter or calling the plan.²⁷ Lilly's guide for prescribers lists a live help line, 1-800-LillyRx, for benefits checks and prior authorization support.²⁸
3. The plan decides, within the deadlines in the timing section.
4. You hear back. Ask the office how you'll get the result; Lilly notes that CoverMyMeds, an electronic prior authorization service, lets prescribers send patients the outcome by text or email.²⁸

Records that answer each criterion

Lilly lists the questions a Zepbound form typically asks. They run from how long you've struggled with your weight to past weight-loss medicines and conditions such as high blood pressure, sleep apnea or heart disease.¹ The answers come from records like these:

• BMI: your current weight and BMI, plus a dated weight from before any weight-loss medicine if your plan uses a pre-treatment BMI (see which BMI counts).
• Diet and lifestyle program: when you joined, who ran it and notes from follow-up visits. Caremark asks for 6 months with continuing follow-up.³
• Weight-related conditions: the diagnoses your plan counts. Lilly notes the qualifying list varies from one formulary to another; high blood pressure, abnormal cholesterol and type 2 diabetes are common ones.^28, 3
• Medicines tried: names, start and stop dates, results and why you stopped each one, which plans such as FEP Blue need for the drugs they want tried first.^29, 6
• Sleep apnea: the sleep study report with its AHI, and records of PAP therapy, including how regularly you use it, an oral appliance or any other sleep apnea treatment you use or have tried. Lilly's guide lists these. UnitedHealthcare's sleep apnea program asks either for symptoms that continue despite regular PAP use (at least 4 hours a night on at least 70% of nights) or for a reason PAP isn't suitable for you.^5, 28, 23

Everything has to match your medical record. Caremark marks its key criteria "Documentation is required for approval," and Lilly asks prescribers for complete and correct information "to avoid denied claims."^3, 28 Never add a diagnosis or change a weight to fit a form.

What the prescriber's letter adds

A letter of medical necessity is a letter your prescriber writes and signs explaining why you need Zepbound. Lilly suggests asking whether to include one, since it may help a request get approved, and posts a sample letter (PDF) for prescribers.^1, 29 Beyond the records above, the sample asks for the diagnosis with its ICD codes and how long you have been in the prescriber's care. It also asks for the clinical reasons for Zepbound and what the prescriber expects without it.²⁹ Ask your prescriber to answer the plan's criteria one by one, in the order the plan lists them.

Diagnosis codes and the drug's NDC

Your prescriber picks codes from your record; Lilly's guide says correct coding is the prescriber's responsibility.²⁸ Codes you may see on these forms, from the code set in use since October 1, 2026 (CMS's 2027 files):³⁰

• E66.811, E66.812 and E66.813: obesity, class 1, 2 or 3. E66.3: overweight.
• Z68.27 to Z68.45: adult BMI ranges, such as Z68.30 for a BMI of 30.0 to 30.9.
• G47.33: obstructive sleep apnea.

The drug itself is identified by its National Drug Code (NDC), and the label lists a different one for each strength and form. So the prescription and the request should name a form your plan covers (see which forms plans cover).¹⁴

How long a decision takes

Federal rules set outer limits, counted from the day the plan receives the request:^{7, 8, 31, 32, 9, 10}

Federal employee plans give their decision times in their brochures. FEP Blue's 2026 brochures promise a prior approval decision within 15 days, with one 15-day extension if matters beyond its control require it, or within 72 hours for an urgent claim.^33, 34

An exception asks a plan to cover a drug that isn't on its list or to waive one of its rules.²⁵ Essential health benefits are 10 categories of care, prescription drugs among them, that every Marketplace plan must cover. Insurers selling individual or small-group coverage outside the Marketplace must include them too.^35, 36 For a Medicare exception, the clock starts when your prescriber's supporting statement arrives.^9, 10

"Urgent" means that waiting the usual time could seriously endanger your life or health, or your ability to regain maximum function. On a private plan it also covers severe pain that a physician who knows your condition says can't be managed without the drug.^7, 27 On a private plan, a request that the clinician treating you calls urgent must be handled as urgent.^7, 31 On a plan with essential health benefits, a drug exception also gets the 24-hour clock if you are already being treated with a drug the plan doesn't list.³² Otherwise, these faster clocks are for real medical urgency, judged by your prescriber, not a shortcut for a routine request.

The clock starts late. It doesn't count the days while your prescriber's office learns a request is needed and gathers records.

In CVS Caremark's 2025 report for Indiana, requests for the Zepbound 2.5 mg single-dose pen were decided an average of 0.24 days, about 6 hours, after Caremark received them. That average includes denials as well as approvals. Appeals for all drugs took an average of 4.18 days.³⁷ That is one company in one state in 2025, so treat it as an example, not a promise.

What slows it down. Missing information can: Optum Rx says it may delay a decision and may lead to a denial. A private plan that extends its deadline because information is missing must say exactly what it needs and give you at least 45 days to send it.^19, 7, 31

If a deadline passes. Ask your prescriber's office whether the request went in, and to which company, then call the number on your plan ID card and ask what is missing. If a plan through work or one you bought misses a federal deadline or otherwise breaks the claims rules, you may be able to skip its internal appeals and go straight to external review. Minor slips that cause no harm may not count.³¹ The free help contacts can tell you which applies. FEP Blue says you may appeal directly to OPM if it doesn't follow required claims processes.^33, 34 For Medicare drug plans, the first of the Medicare steps covers a missed deadline.

Appealing a Zepbound denial, step by step

Your denial letter is the map. On a private plan it must give the specific reason and describe the appeal steps and deadlines. It must also either include the criteria used or say you can have a copy free.⁷ On Medicare, each decision letter explains how to go to the next level.²⁷ You don't have to file alone. Your prescriber can usually ask for the decision or file the appeal for you, though some plans first want a signed form naming them as your representative.^{1, 27, 32, 38, 39}

This section summarizes federal rules as of October 3, 2026; it is not legal advice. Your plan documents and denial letter give your plan's exact steps and deadlines, which can add to these federal minimums but not cut them. State rules can add protections for insurance plans.^7, 31

Plans that state and local governments offer their employees generally follow the same federal rules as private plans.^31, 40 Some plans follow other rules: federal employee plans (below) and older "grandfathered" plans, which federal law generally doesn't require to offer external review.^31, 38 Free help is listed at the end of this section.

Steps by coverage: a plan through work or one you bought, a federal employee plan or a Medicare drug plan. First, match the reason in your letter:

Is it the paperwork, the drug list or the plan itself?

• Missing or outdated records. Ask your prescriber whether to send a new request with what was missing, perhaps with a letter of medical necessity, or to appeal. Lilly notes that some people need more than one appeal.¹
• Criteria not met. Appeal with records that answer each criterion the letter names. If you don't meet one yet, such as a program's length, send a new request once you do.
• Not on the drug list, or another drug preferred. Ask for an exception, a request to cover a drug the plan doesn't list or to waive one of its rules. Caremark notes that plans may call this prior authorization too.²⁵ If you already take a form that Express Scripts' 2027 list excludes and there is a clinical reason to stay on it, your physician can request a coverage review at esrx.com/PA.¹² Ask, too, whether an FDA-approved drug your plan already covers would suit you; Optum Rx notes that a prescriber may choose a covered alternative after a denial.¹⁹ Each drug has its own label warnings.
• An exception refused on an individual or small-group insurance plan. These plans must cover essential health benefits, so you or your prescriber can send the refusal to an independent review organization. That review must be decided within 72 hours, or 24 hours if your request was expedited. An approved standard exception covers the drug for the length of the prescription, refills included; a fast-track one lasts as long as the urgent situation.^36, 32
• Weight-loss drugs excluded. More records won't change a benefit exclusion, though an internal appeal is still allowed. HealthCare.gov's list of denials you can appeal includes "the benefit isn't offered under your health plan." That is most worth doing if a sleep apnea request was handled as a weight-loss one.⁸ External review is for denials involving medical judgment or experimental treatment, so a plain exclusion may not qualify. Still, the external reviewer decides whether medical judgment was involved.^40, 31 Otherwise, what's left is a change to your plan's benefits (on a plan through work, ask your employer) or paying yourself. The sleep apnea route needs a sleep study that has already shown moderate to severe sleep apnea (see the real-diagnosis rule). If you snore, gasp for air in your sleep or are very sleepy during the day, the National Heart, Lung, and Blood Institute suggests asking your healthcare provider about sleep apnea. That is worth doing for your health whatever your coverage.²⁰

Plans through work (except federal employee plans) and plans you buy yourself

1. Get the letter to your prescriber's office. Ask whether they will send a new request or file the appeal; your prescriber can file it for you. On a plan through work, the plan may ask you to sign a form naming your prescriber as your representative. For an urgent request, the treating physician can act for you without one.³⁸
2. Ask for the file. Call your plan, at the number on your ID card, and ask for the criteria it used and the documents in your claim file. A private plan must provide them free on request.^7, 31, 12
3. File within 180 days of the denial notice. Use the plan's appeal form, or write with your name, member ID and claim number, and include your prescriber's letter answering each criterion the denial names. Keep copies of everything.^8, 7
4. Expect an answer within 30 days, or 72 hours if the appeal is urgent. A plan through work with two appeal levels has 15 days for each; a plan you buy yourself has one level.^7, 31
5. If it's still no, ask for external review within 4 months of the final denial; the final letter must tell you how. An independent reviewer decides within 45 days, or 72 hours if expedited, and the decision binds the plan or insurer. It is free under the federal HHS process and costs no more than $25 otherwise. In an urgent case, you can ask for it at the same time as the internal appeal.^8, 40, 31

Federal employee plans, including FEP Blue

FEP Blue is a Federal Employees Health Benefits (FEHB) plan. FEHB plans follow the Office of Personnel Management's (OPM) rule for disputed claims, not the Labor Department and HealthCare.gov appeal rules above.^13, 39, 38

1. Ask the plan in writing to reconsider within 6 months of the denial notice, giving the reasons, in terms of your plan brochure, that it should have been approved. Someone acting for you, such as your prescriber, needs your written consent.³⁹
2. The plan has 30 days to pay or provide the service, confirm the denial in writing, or ask you or your prescriber for more information. If it asks, you have 60 days to send the information, and the plan then has 30 days to decide. If nothing arrives, it decides on what it has.³⁹
3. If it says no again, ask OPM to review it within 90 days of the plan's letter, which must tell you about this right and deadline. If the plan doesn't answer in time, you can still ask OPM. Do so within 120 days of your request to the plan, or of the plan's request for more information if it asked. You must finish both steps before going to court.³⁹

Medicare drug plans

By law, weight-loss use falls outside the definition of a Part D drug, so the basic Part D benefit doesn't cover Zepbound for weight loss alone. An exception can't be used to get coverage for a drug or use outside Part D.^41, 42, 43 A plan with enhanced coverage can add weight-loss drugs as an extra (supplemental) benefit, so check your plan's drug list.^41, 44

The steps below are for a use your plan covers. Part D plans can cover Zepbound for moderate to severe obstructive sleep apnea, and Medicare.gov says your plan might cover it.^45, 46 If your plan's extra coverage includes Zepbound for weight loss, the same steps apply when the plan says no under its rules. The difference is that you ask for a coverage determination rather than an exception, since the exception route is only for Part D drugs.^47, 43 If your request was for weight loss and your plan's benefits don't include it, the steps won't get it covered. The Medicare GLP-1 Bridge is the route if you qualify.

The Medicare GLP-1 Bridge is run by CMS from July 1, 2026 to the end of 2027. It lets eligible people with Part D get the Zepbound KwikPen, when it is prescribed for weight management, for $50 per one-month supply. Anyone whose Part D plan already covers a GLP-1 for them is among those excluded. Its prior authorization has no appeals process; a prescriber can only resubmit with corrected or new information (how the Bridge works and who qualifies).^45, 46

1. Ask for a coverage determination or an exception. A coverage determination is the plan's first decision on your drug, and you or your prescriber can ask for one. An exception also needs your prescriber's statement of the medical reason, though that statement doesn't ensure approval.^27, 43 The plan decides within 72 hours, or 24 hours if your health can't wait; for an exception, the clock starts when the statement arrives. If it misses the deadline, the request counts as denied and goes to an independent review entity within 24 hours.^9, 10
2. Level 1, redetermination: within 65 days of the date on the denial notice, ask the plan to look at its decision again. If you file late, you must give a reason. Include your name, address and Medicare Number, the drug and why you are appealing, and anything that may help, such as a supporting statement from your prescriber. The plan decides within 7 days, or 72 hours for a fast appeal. A request to be paid back for a drug you already bought gets 14 days.²⁷
3. Level 2: independent review. If the plan says no again, you have 60 days to ask a Part D independent review entity (IRE) to review it. It decides within 7 days, or 72 hours if fast, and 14 days for a payment request.²⁷
4. Levels 3 to 5. A decision by the Office of Medicare Hearings and Appeals, then a review by the Medicare Appeals Council, then federal district court. Each is asked for within 60 days of the decision before it. Levels 3 and 5 also require a minimum amount in dispute.²⁷

Medicaid, TRICARE and the VA have their own processes. See Medicaid appeals and fair hearings and our TRICARE and VA page.

Free help with an appeal

• A plan through work or one you bought: your state's insurance department, or its Consumer Assistance Program, may be able to help. HealthCare.gov says that program can file an appeal for you.^40, 8 Not every state has one. CMS's state map gives each state's program or, where there is none, other contacts such as the state insurance department and the U.S. Department of Labor.⁴⁸
• A plan through a private employer: the Labor Department's Employee Benefits Security Administration (EBSA) has benefits advisors at 1-866-444-3272.³⁸
• Medicare: 1-800-MEDICARE (1-800-633-4227), or your State Health Insurance Assistance Program (SHIP), which offers free counseling and helps people with Medicare file appeals.^27, 49
• A federal employee plan: the plan's letter confirming a denial must explain how to ask OPM for review.³⁹

Keeping coverage: approval periods and renewals

Approvals expire, and the first is often the shortest. For weight management, the four documents set these terms (sleep apnea renewals are in the sleep apnea section):

An approval covers a period of time, not one dose. Caremark's criteria set quantity limits per fill: for the 2.5 mg pen, one 4-pen carton every 21 days for a 28-day fill, a gap that leaves time to process refills.³ Lilly's guide notes that some renewals depend on how long you have been on a stable maintenance dose. It tells prescribers to request "continuation of therapy" and document your treatment history.²⁸ If you change plans, you may have to start over: Prime, for example, sends anyone it hasn't approved before through a new initial review.⁵

Ask the office to file each renewal before the approval ends. If coverage lapses and you miss doses, ask your prescriber how to restart rather than going back to your last dose on your own.

The label warnings a prior authorization doesn't cover

Plans check only a few safety points. Lilly's guide lists "no concurrent use of other GLP-1 agonists or other weight loss medications" and "no history of pancreatitis" among typical criteria.²⁸ Prime requires that you have none of the label's contraindications.⁵ The rest of the Zepbound label is for you and your prescriber to go over before you start:¹⁴

• Zepbound is not for you if you or anyone in your family has had medullary thyroid carcinoma (MTC), a kind of thyroid cancer. It is also not for you if you have the endocrine condition MEN 2 (multiple endocrine neoplasia syndrome type 2). Nor is it for you if tirzepatide or another ingredient in it has ever caused you a serious allergic reaction. The boxed warning exists because tirzepatide caused thyroid C-cell tumors in rat studies; whether it does so in people, MTC included, is unknown.
• Pregnancy, breastfeeding and birth control. Tell your prescriber if you are pregnant or plan to become pregnant. The label warns that Zepbound may harm an unborn baby; stop it and tell your prescriber once you know you're pregnant. If you breastfeed or plan to, ask your prescriber first, because the Medication Guide says Zepbound may pass into breast milk. If you rely on birth control pills, the label advises using a non-pill method instead, or a barrier method as well. The label advises this during your first 4 weeks on Zepbound and for 4 weeks after each increase in dose.
• Other drugs. The label advises against using it with other products that contain tirzepatide, such as Mounjaro, or with any GLP-1 drug. Compounded semaglutide and tirzepatide fall in those groups. Taking it with insulin or with a sulfonylurea (a diabetes medicine) raises the chance of low blood sugar, including severe episodes. So your prescriber may need to lower those doses and, if you have diabetes, check your blood sugar before and during treatment. Low blood sugar has also been reported in adults who don't have type 2 diabetes. Because Zepbound delays stomach emptying, it may affect how well pills you swallow are absorbed, and the label asks for closer monitoring of some, such as warfarin. Tell your prescriber about every medicine you take.
• Under 18. It has not been shown to be safe and effective in anyone younger than 18.
• KwikPens. Never share one, not even with a fresh needle; the label warns that sharing can pass on blood-borne infections.

Other risks the label describes:¹⁴

• Stomach and bowel side effects that can be severe. The label doesn't recommend Zepbound if you have severe gastroparesis (seriously slowed stomach emptying).
• Pancreatitis (an inflamed pancreas), including severe and fatal cases. Tell your prescriber if you have ever had pancreas problems.
• A higher rate of gallbladder disease.
• Kidney damage from dehydration, sometimes bad enough to need dialysis.
• Serious allergic reactions.
• Diabetic eye disease getting worse, for people with type 2 diabetes. Tell your prescriber if you have ever had this eye disease, called diabetic retinopathy.
• Stomach contents being inhaled into the lungs under anesthesia or deep sedation, which is why anyone planning a procedure for you should know you take it.

A pending request or appeal is never a reason to wait. Here is what the Medication Guide says to do:¹⁴

• Stomach pain that is severe and won't go away, which can spread to your back, whether or not you are nauseated or vomiting. Stop Zepbound and call your prescriber right away.
• A possible serious allergic reaction, such as a swollen face, lips, tongue or throat, trouble breathing or swallowing, a severe rash or itching, fainting or dizziness, or a very rapid heartbeat. Stop Zepbound and get medical help right away.
• Diarrhea, nausea or vomiting that keeps going, or signs of gallbladder trouble (upper stomach pain, fever, yellowing of your skin or eyes, clay-colored stools). Tell your prescriber right away, and keep drinking fluids so you don't become dehydrated.
• Hoarseness, a lump or swelling in your neck, trouble swallowing or shortness of breath, which the guide lists as possible symptoms of thyroid cancer, and, with type 2 diabetes, any change in your vision. Tell your prescriber.
• Low blood sugar: know the signs before you start. The guide lists dizziness or light-headedness, sweating, confusion or drowsiness, headache, blurred vision, slurred speech, shakiness, a fast heartbeat, anxiety, irritability or mood changes, hunger, weakness and feeling jittery.
• An overdose: call your prescriber or Poison Help (1-800-222-1222), or go to the nearest emergency room right away.

The label lists more than this. See the full prescribing information, plus the Medication Guide packed with every fill, and go through both with your prescriber before you start.

If coverage is out of reach

Paying without insurance. As of October 3, 2026, Zepbound single-dose vials are sold only through Lilly's LillyDirect. The 2.5 mg starting dose costs $299 for 28 days (the label uses it for the first 4 weeks only, not as a maintenance dose). The 5 mg dose costs $399. The higher doses cost $449 if you buy each refill within 45 days of receiving the previous one, and $499 to $699 otherwise.^50, 51, 14 Needles and syringes are extra, and the label says to use a new needle and syringe for every injection.^50, 14 People with Medicare, Medicaid or other government coverage can pay these cash prices if they don't bill their plan.⁵²

People in government plans can't use Lilly's commercial savings card. It gives as little as $25 a fill for covered single-dose pens, within monthly and annual caps, or from $499 a month when the plan doesn't cover them. Lilly's separate KwikPen self-pay card, for cash buyers including government enrollees, prices KwikPens like the vials above for up to 11 fills a calendar year (pen needles extra). Both cards end December 31, 2026.^51, 52 See which offers fit your coverage and a year of Zepbound, fill by fill.

Compounded tirzepatide. It is not approved by FDA, which does not review compounded drugs for safety, effectiveness or quality before they are sold. FDA says they "should only be used in patients whose medical needs cannot be met by an FDA-approved drug."¹⁶ So compounded tirzepatide is a medical judgment a prescriber would need to justify, not a fallback for a denied claim.

Nor does it come with an FDA-approved label or Medication Guide, so a prescriber would need to go through the warnings above with you. By May 31, 2026, FDA had received more than 730 reports of adverse events associated with compounded tirzepatide. It says many resemble the known side effects of the approved drugs. It also has reports that may be related to compounded semaglutide or tirzepatide prescribed in doses beyond the approved label. Those counts likely understate the problem, FDA adds, since state-licensed pharmacies that aren't outsourcing facilities have no federal duty to report to it.¹⁶ Our guide to compounded tirzepatide covers the legal limits and how to check a provider.

If Zepbound's approved uses don't fit you. Zepbound is approved only for adults and only for the two uses above. If you are under 18, it would be off-label for you. It would also be off-label if you don't have obesity, overweight with a weight-related condition, or moderate to severe sleep apnea with obesity. In both cases you wouldn't meet the adult criteria described above.¹⁴ Take the question to your own doctor, not to an online seller of weight-loss drugs. PlexusDx is one such seller, and its programs are open only to adults 18 and older. Our page on GLP-1 drugs when you don't have obesity or overweight covers that situation.

About our own programs: PlexusDx's compounded GLP-1 programs are self-pay, and PlexusDx doesn't bill health insurance, so you would pay the full cost yourself (as of October 19, 2026; see PlexusDx's Terms of Service). FDA's caution above applies to them, and our provider guide puts the same checks to PlexusDx.

Sources

1. Zepbound Access & Coverage, Eli Lilly and Company, accessed October 3, 2026.
2. Preauthorization (glossary), HealthCare.gov, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
3. Initial Prior Authorization with Quantity Limit: Zepbound Weight Loss Management (criteria 6192-C, P08-2025), CVS Caremark, accessed October 3, 2026.
4. Weight Loss: Glucagon-Like Peptide-1 Agonists Prior Authorization Policy (revised April 15, 2026), Express Scripts, accessed October 3, 2026.
5. Weight Management Prior Authorization with Quantity Limit Program Summary (Commercial, effective July 1, 2026), Prime Therapeutics, accessed October 3, 2026.
6. Zepbound, policy 5.99.031 (effective July 1, 2026), Blue Cross Blue Shield Association, Federal Employee Program (hosted by CVS Caremark), accessed October 3, 2026.
7. 29 CFR 2560.503-1, Claims procedure, U.S. Department of Labor, Electronic Code of Federal Regulations, accessed October 3, 2026.
8. Internal appeals, HealthCare.gov, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
9. 42 CFR 423.568, Standard timeframe and notice requirements for coverage determinations, Centers for Medicare & Medicaid Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
10. 42 CFR 423.572, Timeframes and notice requirements for expedited coverage determinations, Centers for Medicare & Medicaid Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
11. CVS Caremark delivers affordability and access to GLP-1 weight management medications with expanded coverage options (May 28, 2026), CVS Health, accessed October 3, 2026.
12. 2027 National Preferred Formulary Exclusions, Express Scripts, accessed October 3, 2026.
13. About Us, Blue Cross and Blue Shield's Federal Employee Program, accessed October 3, 2026.
14. ZEPBOUND (tirzepatide) injection: prescribing information and Medication Guide (revised August 2026), Eli Lilly and Company, via DailyMed, National Library of Medicine, accessed October 3, 2026.
15. Provider information on our GLP-1 program (EncircleRx), Evernorth Health Services, accessed October 3, 2026.
16. FDA's concerns with unapproved GLP-1 drugs used for weight loss, U.S. Food and Drug Administration, accessed October 3, 2026.
17. Exception Criteria: Tirzepatide (6981-A, P08-2025 v5), CVS Caremark, accessed October 3, 2026.
18. Diabetes: Glucagon-Like Peptide-1 Agonists Prior Authorization Policy (revised May 6, 2026), Express Scripts, accessed October 3, 2026.
19. Your guide to the OptumRx PA process: PA guidelines and procedures, Optum Rx, accessed October 3, 2026.
20. Sleep Apnea: What Is Sleep Apnea?, National Heart, Lung, and Blood Institute, National Institutes of Health, accessed October 3, 2026.
21. Central sleep apnea (Medical Encyclopedia), MedlinePlus, National Library of Medicine, accessed October 3, 2026.
22. Epworth Sleepiness Scale (archived training page), National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, accessed October 3, 2026.
23. Prior Authorization/Non-Formulary: Zepbound (tirzepatide), Obstructive Sleep Apnea Only (Program 2026 P 1475-3, effective September 1, 2026), UnitedHealthcare, accessed October 3, 2026.
24. Prior Authorization/Notification: Weight Loss/Appetite Suppression Medication Coverage (Program 2026 P 1114-23, effective October 1, 2026), UnitedHealthcare, accessed October 3, 2026.
25. Prior Authorization Information, CVS Caremark, accessed October 3, 2026.
26. 2025 Employer Health Benefits Survey, KFF, accessed October 3, 2026.
27. Appeals in a Medicare drug plan, Medicare.gov, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
28. Zepbound Prior Authorization Resource Guide, Eli Lilly and Company, accessed October 3, 2026.
29. Sample Letter of Medical Necessity (Zepbound), Eli Lilly and Company, accessed October 3, 2026.
30. 2027 Code Descriptions in Tabular Order (ICD-10-CM), Centers for Medicare & Medicaid Services, accessed October 3, 2026.
31. 45 CFR 147.136, Internal claims and appeals and external review processes, U.S. Department of Health and Human Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
32. 45 CFR 156.122, Prescription drug benefits, U.S. Department of Health and Human Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
33. Blue Cross and Blue Shield Service Benefit Plan, 2026 brochure: FEP Blue Standard and FEP Blue Basic (RI 71-005), Blue Cross and Blue Shield Association, Federal Employee Program, accessed October 3, 2026.
34. Blue Cross and Blue Shield Service Benefit Plan, 2026 brochure: FEP Blue Focus (RI 71-017), Blue Cross and Blue Shield Association, Federal Employee Program, accessed October 3, 2026.
35. What Marketplace health insurance plans cover, HealthCare.gov, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
36. 45 CFR 147.150, Coverage of essential health benefits, U.S. Department of Health and Human Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
37. Caremark 2025 Indiana Annual UR Report, CVS Caremark, accessed October 3, 2026.
38. Filing a Claim for Your Health Benefits, Employee Benefits Security Administration, U.S. Department of Labor, accessed October 3, 2026.
39. 5 CFR 890.105, Filing claims for payment or service, U.S. Office of Personnel Management, Electronic Code of Federal Regulations, accessed October 3, 2026.
40. External Review, HealthCare.gov, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
41. 42 U.S. Code 1395w-102, Prescription drug benefits, Legal Information Institute, Cornell Law School, accessed October 3, 2026.
42. 42 U.S. Code 1396r-8, Payment for covered outpatient drugs, Legal Information Institute, Cornell Law School, accessed October 3, 2026.
43. 42 CFR 423.578, Exceptions process, Centers for Medicare & Medicaid Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
44. 42 CFR 423.104, Requirements related to qualified prescription drug coverage, Centers for Medicare & Medicaid Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
45. Medicare GLP-1 Bridge: Information for Providers, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
46. Weight loss drugs, Medicare.gov, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
47. 42 CFR 423.566, Coverage determinations, Centers for Medicare & Medicaid Services, Electronic Code of Federal Regulations, accessed October 3, 2026.
48. Consumer Assistance Program, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
49. Talk to Someone, Medicare.gov, Centers for Medicare & Medicaid Services, accessed October 3, 2026.
50. Zepbound, LillyDirect, Eli Lilly and Company, accessed October 3, 2026.
51. Zepbound full terms and conditions, Eli Lilly and Company, accessed October 3, 2026.
52. Savings & Insurance Options | Zepbound, Eli Lilly and Company, accessed October 3, 2026.

How we made this page

The rules that decide a Zepbound request sit in four plans' criteria, Lilly's guides and several sets of federal appeal rules. On October 3, 2026, AI tools read those documents and pulled the same facts from each: BMI, program length, drugs to try first, approval length, renewal rule, covered forms and every appeal deadline. AI tools also wrote the draft. The plan facts rest mainly on Caremark's criteria 6192-C and 6981-A, Express Scripts' weight-loss policy and 2027 exclusion list, Prime's July 1, 2026 program and FEP Blue's policy 5.99.031 and 2026 brochures; the appeal steps on the Labor Department's claims rule, the HHS rules for group and individual plans and drug exceptions, OPM's rule for federal employee plans and Medicare's Part D rules; and the safety section on the Zepbound label revised in August 2026.

Each factual statement about a plan, a rule or the drug is tied to a quoted passage in our evidence file. A script searched the plan documents, rules and labels for every one of those passages and flagged any it could not find. Over several rounds, AI reviewers then looked for factual, clinical, regulatory, search-policy, PlexusDx-claim and reader problems, and an AI editor revised the page to fix what they found. The automated checks compare words with sources; they are not a medical or legal opinion. The how-to suggestions, such as answering each criterion in order, are our advice rather than quotes, and what the page says about PlexusDx's programs comes from PlexusDx's published Terms of Service, dated October 19, 2026.

The page is not legal advice, and while making it we sent no request to any plan and spoke with no plan reviewer. The older post at this address treated Caremark's 2025 removal of Zepbound as current, gave approval times we could not trace and appeal statistics that did not concern drug coverage, and pitched PlexusDx's compounded programs as a way to skip prior authorization; this page keeps none of it. Lilly, CVS Caremark, Express Scripts, Evernorth, Prime Therapeutics, FEP Blue, Optum Rx, UnitedHealthcare and Anthem are named only to identify their own documents; none of them is affiliated with this page, and none sponsored, reviewed or endorsed it.

Jay Hastings reviewed and approved this version on October 19, 2026. Dr. Asad K. Niazi, MD, MPH, reviewed the medical content on October 17, 2026. He is co-founder and CEO of Lone Star Virtual Health, the company that provides PlexusDx's prescribing clinicians, so he has a business relationship with PlexusDx. PlexusDx sells compounded GLP-1 treatment, so we have a financial interest in this topic. Read our editorial policy.