Does Medicare cover Zepbound in North Carolina?

What Zepbound is used for

Zepbound is tirzepatide, a once-weekly injection that acts on two gut hormones (GLP-1 and GIP). Its FDA label includes chronic weight management in adults with obesity, or with overweight and a weight-related health problem, together with diet and exercise; and, since December 20, 2024, moderate to severe obstructive sleep apnea in adults with obesity. Mounjaro is the same medicine, approved for type 2 diabetes.

This page explains Medicare coverage only. Questions about whether Zepbound is right for you belong with your prescriber.

Which part of Medicare covers Zepbound

Zepbound is self-injected, so any Medicare coverage runs through Part D, in one of two ways:

• Your Part D plan can cover Zepbound for a medically accepted use that isn't weight loss alone, such as obstructive sleep apnea, if Zepbound is on its formulary. Expect prior authorization.
• The Medicare GLP-1 Bridge covers the Zepbound KwikPen for weight management when you meet CMS's criteria, outside your plan's formulary.

Federal law (Social Security Act §1860D-2(e)) excludes drugs used for weight loss from Part D, which is why a plan can't cover Zepbound for weight loss on its own.

How the Medicare GLP-1 Bridge works for Zepbound

• Dates: coverage started July 1, 2026, and CMS extended it through December 31, 2027. CMS hasn't announced coverage after that.
• Which Zepbound: only the Zepbound KwikPen. Medicare.gov says the Bridge doesn't cover single-dose Zepbound vials or pens. It also covers Wegovy and Foundayo.
• Who qualifies: people with Part D, 18 or older, with a BMI of 35 or more; or 30 or more with diastolic heart failure, uncontrolled high blood pressure or stage 3a or later kidney disease; or 27 or more with prediabetes, a past heart attack or stroke, or peripheral artery disease with symptoms.
• Who doesn't: people who already get a GLP-1 through their Part D plan, and people with type 2 diabetes, moderate to severe sleep apnea or fatty liver disease. For those conditions, your Part D plan might cover a GLP-1 instead.
• How: your prescriber sends the prescription and completes the prior authorization, certifying you're in a diet and exercise program. You pay a flat monthly copay set by CMS, shown on Medicare.gov.
• Limits: the Bridge copay doesn't count toward your Part D deductible or the $2,400 cap, and Extra Help and the Medicare Prescription Payment Plan can't be used for it.

Check eligibility at Medicare.gov/glp1bridge or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).

Is Zepbound on Medicare's negotiated-price list?

Zepbound is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far: the 10 drugs with negotiated prices since January 1, 2026, the 15 with negotiated prices starting January 1, 2027, and the 15 CMS selected on January 27, 2026, for prices that take effect in 2028.

What you pay for Zepbound in 2027: the out-of-pocket cap

Your cost for Zepbound depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred pharmacy. This site doesn't list plan costs; your plan's formulary and Evidence of Coverage do. What Medicare sets for everyone with Part D is the limit:

• 2027 out-of-pocket cap: $2,400 (it was $2,100 in 2026). Once what you pay for covered Part D drugs (deductible, copays and coinsurance) reaches the cap, you pay nothing more for covered Part D drugs for the rest of 2027.
• The maximum Part D deductible for 2027 is $700. No plan can set a higher deductible.
• Only covered drugs count. If your plan doesn't cover Zepbound and you pay cash, or you use a discount card instead of your plan, that spending doesn't count toward the cap.

These cost rules apply when your Part D plan covers Zepbound, for example for sleep apnea. Zepbound through the GLP-1 Bridge has its own copay, which doesn't count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan lets you pay your Part D drug costs in monthly bills from your plan across the calendar year instead of all at once at the pharmacy. Medicare.gov says there's no cost to participate, but it doesn't lower your drug costs; it only changes when you pay. It helps most when your costs are high early in the year. To join, call your plan or use its website. More in What is the Medicare Prescription Payment Plan?

Extra Help with Zepbound

Extra Help (the Low-Income Subsidy) is a federal program that lowers Part D premiums, deductibles and copays. For 2027, CMS caps Extra Help copays for covered drugs at $5.80 for a generic and $14.40 for a brand-name drug, and some people with full Medicaid pay less. You get Extra Help automatically if you have full NC Medicaid, SSI or a Medicare Savings Program, which North Carolina calls MQB (MQB-Q, MQB-B or MQB-E). Otherwise, apply through Social Security at ssa.gov/extrahelp or 1-800-772-1213 (TTY 1-800-325-0778). See Extra Help in North Carolina and MQB in North Carolina.

Getting Zepbound covered in North Carolina

North Carolina is its own Part D region (PDP Region 08), so each standalone Part D plan sold here is offered in all 100 counties. For 2027, CMS lists 11 standalone Part D plans from 6 companies in North Carolina. Every county also has Medicare Advantage plans open to everyone, from 11 in Carteret County to 57 in Guilford County. Each plan has its own formulary, so one plan's coverage of Zepbound tells you nothing about another's. Your county's numbers are on North Carolina counties.

State Health Plan retirees: the Plan's Base Plan and Enhanced Plan are group Medicare Advantage plans that include group Part D, so your Zepbound coverage comes from the Plan's formulary. Don't join a separate Part D or Medicare Advantage plan to get Zepbound covered: the State Health Plan says that removes you from its group Medicare Advantage plan and moves you to the 70/30 Plan. Ask the Plan first. See the State Health Plan and Medicare.

If you have full NC Medicaid and Medicare, your Medicare drug coverage, not NC Medicaid, pays for Part D drugs like Zepbound, and you get Extra Help automatically. See NC Medicaid and Medicare.

If your Medicare Advantage plan ends in 2027, your plan sends a non-renewal letter, and you have a special enrollment period through February 28, 2027. To keep Zepbound covered without a gap, choose new drug coverage by December 31, 2026. See plans ending in 2027.

Hurricanes and power outages: Zepbound has storage-temperature limits on its label, so a long power outage can ruin your supply; keep your plan's pharmacy number with your emergency supplies. CMS says Medicare pays to replace prescription drugs lost, destroyed or damaged in a disaster; call your plan for a replacement fill. North Carolina's emergency-refill law (G.S. 58-3-228) is written for state-regulated health plans and the State Health Plan; in a Medicare drug plan, ask the plan itself. See early refills before a hurricane.

Military retirees: since August 31, 2025, the TRICARE pharmacy benefit doesn't cover weight-loss drugs for TRICARE For Life beneficiaries when obesity is the primary diagnosis. TRICARE isn't on Medicare.gov's list of drug coverage that qualifies for the GLP-1 Bridge; that list requires Medicare drug coverage. See military, veterans and TRICARE in North Carolina.

How to check whether a plan covers Zepbound

1. Write down the exact drug. Name, strength and how often you take it. A plan can cover one form of Zepbound and not another.
2. Look it up in each plan's formulary. Enter your drugs and ZIP code on PlanMatch or Medicare.gov's Plan Finder to see which plans list Zepbound and any rules.
3. Read the rules next to the drug. Prior authorization, step therapy or quantity limits mean your prescriber may need to send the plan information before it pays.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Zepbound stays on the formulary next year. Open Enrollment runs October 15 to December 7, 2026, for coverage starting January 1, 2027.
5. Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

If your plan doesn't cover Zepbound, you or your prescriber can ask for a coverage determination or a formulary exception. Once the plan has your prescriber's supporting statement, it generally must decide within 72 hours, or 24 hours if your prescriber says waiting could seriously harm your health. New members can usually get a one-time transition supply of a drug they were already taking while they ask for an exception or switch. See How do I appeal a Medicare denial in North Carolina?

Sources

• National Library of Medicine — DailyMed: Zepbound prescribing information (FDA label)
• Medicare.gov — Medicare GLP-1 Bridge
• CMS — Medicare GLP-1 Bridge (July 1, 2026 – December 31, 2027)
• FDA — FDA approves first medication for obstructive sleep apnea (Zepbound, December 20, 2024)
• Social Security Act §1860D-2(e) (drugs excluded from Part D, including drugs for weight loss)
• Medicare.gov — Drug coverage (Part D)
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• CMS — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold, deductible and Extra Help copays)
• Medicare.gov — Medicare Prescription Payment Plan
• Social Security — Extra Help with Medicare prescription drug plan costs
• eCFR — 42 CFR 423.120 (formularies and transition fills)
• CMS — Medicare Advantage and Part D Landscape files, 2027 (PDP Region 08: North Carolina)
• State Health Plan — Retiree presentation (group Medicare Advantage plans, outside Medicare plans and the 70/30 Plan)
• CMS — Replacing Durable Medical Equipment and Prescription Drugs after a Disaster
• North Carolina General Statutes — G.S. 58-3-228, extra prescriptions during a state of emergency or disaster
• TRICARE — TRICARE For Life (weight-loss drug coverage)

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