Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (HTN, T2DM, and dyslipidemia)
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Obesity (BMI >= 30)
All of:
- Adult patient (18+)
- Participated in a comprehensive weight management program with behavioral modification, reduced-calorie diet, and increased physical activity with continuing follow-up for at least 6 months prior to drug therapy
- Baseline BMI >= 30 kg/m2
- Used with a reduced-calorie diet and increased physical activity
Overweight with comorbidity (BMI >= 27)
All of:
- Adult patient (18+)
- Participated in a comprehensive weight management program with behavioral modification, reduced-calorie diet, and increased physical activity with continuing follow-up for at least 6 months prior to drug therapy
- Baseline BMI >= 27 kg/m2
- Used with a reduced-calorie diet and increased physical activity
Plus any one of:
- Hypertension
- Type 2 diabetes mellitus
- Dyslipidemia
Documentation to bring
- Baseline BMI documentation (>= 30 kg/m2 OR >= 27 kg/m2 with comorbidity; if transitioning from another weight loss drug, baseline BMI at start of any drug therapy)
- Documentation of at least one weight-related comorbid condition if baseline BMI is >= 27 and < 30 kg/m2 (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)
- Documentation of participation in a comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity with continuing follow-up) for at least 6 months prior to drug therapy
Quantity limits
- 2.5mg/0.5mL, 5mg/0.5mL, 7.5mg/0.5mL, 10mg/0.5mL, 12.5mg/0.5mL, 15mg/0.5mL — 2 mL (4 pre-filled single-dose pens) / 21 days; 6 mL (12 pre-filled single-dose pens) / 63 days (84-day)
- 2.5mg/0.6mL, 5mg/0.6mL, 7.5mg/0.6mL, 10mg/0.6mL, 12.5mg/0.6mL, 15mg/0.6mL — 2.4 mL (1 single-patient-use KwikPen) / 21 days; 7.2 mL (3 single-patient-use KwikPens) / 63 days (84-day)
Approval and renewal
- Initial approval: 8 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, Patient must have completed at least 3 months of therapy at a stable maintenance dose AND lost at least 5% of baseline body weight OR continued to maintain their initial 5% weight loss. BMI and lifestyle program requirements are not re-verified at continuation, and at least 12 weeks on therapy before the first renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Coadministration with other tirzepatide-containing products is not recommended
- Coadministration with any GLP-1 receptor agonist is not recommended
- Vials are excluded (covered under LillyDirect manufacturer program)
- OTC products are not included
Policy note: Baseline BMI is defined as BMI at the start of any drug therapy when patient is transitioning from another weight loss medication. The 28-day fill period uses 21-day supply and the 84-day fill period uses 63-day supply to allow time for refill processing.
verified June 2, 2026 · source: 6192-C_Zepbound.pdf