TRICARE Zepbound coverage and appeal checklist

Before the request

• Enrolled in a TRICARE Prime or Select plan, not TRICARE For Life
• Exact product looked up in the TRICARE Formulary Search Tool: pen, vial or KwikPen
• Prior authorization form downloaded from that product's result
• Prescriber is an MTF or TRICARE network provider who has assessed you
• Indication confirmed: weight management, or moderate to severe obstructive sleep apnea
• If you also have Medicare, asked which program will process the prescription

What the prescriber documents (adult weight-management pathway)

Coverage rules from TRICARE, Express Scripts and Medicare

• Weight-loss drugs including Zepbound are covered for TRICARE Prime and Select beneficiaries with an approved prior authorization.[1]
• TRICARE does not cover weight-loss drugs for TRICARE For Life beneficiaries.[2]
• Initial approval lasts 12 months, and annual renewal is required.[3]
• The adult initial pathway asks for at least 6 months of behavioral modification and dietary restriction, documented in the medical record.[3]
• The step question asks about 3 months of a named generic weight-loss drug without a 5% drop in baseline weight, with exception branches.[3]
• Weight-management renewal asks for at least 5% loss of baseline weight since starting, after full dose titration.[3]
• Medicare's GLP-1 Bridge, from July 1, 2026, covers Zepbound KwikPen only, with a $50 copayment for a one-month supply.[4]

Request and appeal tracker

Pharmacy appeal rules

• Send the appeal letter to Express Scripts with a postmark within 90 days of the decision date.[5]
• State specifically why you disagree, and include a copy of the decision and any supporting documents.[5]
• If some documents are not ready, send the appeal with what you have and say more will follow.[5]
• If Express Scripts denies the appeal, its decision letter explains how to request a second-level appeal.[5]

Appeal packet contents

• Copy of the denial or claim decision
• Your letter saying specifically why you disagree
• Prescriber's letter addressing the criterion the denial names
• Chart notes with BMI and weight-related conditions
• Records of the lifestyle program and how long it ran
• Records of the generic drug tried, or of the exception that applies
• A note listing any records still to come

Questions for Express Scripts or the pharmacy

1. Was the request reviewed on the initial or the renewal pathway?
2. Is more information needed, and from whom?
3. What quantity and days' supply are authorized?
4. What will this fill cost for my beneficiary category, at this pharmacy or by home delivery?
5. Does the pharmacy have the covered product in stock?
6. When does this approval end, and when should the renewal request go in?