TennCare covers Zepbound for weight loss as of August 1, 2025. The drug sits on the preferred list, so you do not have to fail cheaper medications first, but your prescriber must submit a prior authorization form with chart notes showing you meet TennCare’s clinical criteria.1Centers for Medicare & Medicaid Services. Tennessee State Plan Amendment TN-25-00062OptumRx / TennCare. Provider Notice – Obesity Management Agents
Who Qualifies
You must be 18 or older and meet one of two weight thresholds, documented in your medical records:
- A BMI of 30 or higher, or
- A BMI of 27 or higher along with a weight-related condition such as hypertension, dyslipidemia, diabetes, coronary heart disease, MASH/NASH, or obstructive sleep apnea.
Your prescriber also has to confirm that you are actively working on complementary lifestyle changes, meaning dietary modification, physical activity, or behavioral intervention. Zepbound cannot be layered with other FDA-approved weight-loss drugs or with any other GLP-1 receptor agonist. And you cannot have a personal or immediate family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN2).3OptumRx / TennCare. Obesity Management Agents PA Form2OptumRx / TennCare. Provider Notice – Obesity Management Agents
For enrollees under 18, weight must be above the 95th percentile for age and sex. Keep in mind that Zepbound’s FDA label is approved for adults.2OptumRx / TennCare. Provider Notice – Obesity Management Agents
How the Prior Authorization Works
Your provider submits an Obesity Management Agents PA form to OptumRx, TennCare’s pharmacy benefits manager, along with chart notes documenting your BMI, any qualifying comorbidity, and your engagement in lifestyle changes.3OptumRx / TennCare. Obesity Management Agents PA Form Because Zepbound is a preferred agent, there is no step-therapy requirement to try older weight-loss medications first. That is different from non-preferred drugs like Saxenda, Evekeo, and Imcivree, where TennCare requires documented trial and failure of two preferred agents before it will approve coverage.2OptumRx / TennCare. Provider Notice – Obesity Management Agents
Starting in January 2026, initial prior authorization approvals for GLP-1 weight management drugs run only three months. That means your provider will need to reauthorize relatively quickly after you start.4OptumRx / TennCare. Provider Notice – Weight Management Updates
Staying on Zepbound: The 5% Rule
Continued coverage is conditional. When your provider seeks renewal, TennCare requires medical records showing you have lost at least 5% of your baseline body weight. You must also still be participating in lifestyle changes and not combining Zepbound with any other weight-loss drug.2OptumRx / TennCare. Provider Notice – Obesity Management Agents
If you do not hit the 5% threshold, TennCare may approve one additional month of coverage so you can taper off the medication gradually rather than stopping abruptly.2OptumRx / TennCare. Provider Notice – Obesity Management Agents
Quantity Limits and Refill Rules
TennCare limits Zepbound to four injections per month, matching the once-weekly dosing schedule.2OptumRx / TennCare. Provider Notice – Obesity Management Agents
In December 2025, TennCare tightened the rules on all GLP-1 receptor agonists. You can only fill one GLP-1 agent at a time. Refills process only after you have used 85% of the previous fill period, and that rule applies even when you switch products or change dose strengths. Pharmacies cannot use override codes to bypass therapeutic duplication rejections at the counter. Pharmacists can call OptumRx to request an override for a legitimate titration or product change, but overrides are capped at three per rolling calendar year.4OptumRx / TennCare. Provider Notice – Weight Management Updates
Practically, that means if your prescriber moves you from the 5 mg dose to 10 mg partway through a month, you will not automatically get an early refill of the higher strength. The pharmacy will need to call OptumRx, and each of those calls counts against the three-per-year cap.
How Zepbound Is Taken
Zepbound is a once-weekly injection under the skin of the abdomen, thigh, or upper arm. Patients start at 2.5 mg per week and gradually work up over several weeks to a maintenance dose of 5 mg, 10 mg, or 15 mg. The maximum dose is 15 mg.5U.S. Food and Drug Administration. Zepbound Prescribing Information
A note on the active ingredient: Zepbound and Mounjaro both contain tirzepatide, but their FDA approvals are different. Mounjaro is approved for blood sugar control in type 2 diabetes; Zepbound is approved for chronic weight management in adults with obesity or with a BMI of 27 or higher plus a weight-related condition. You should not take both, and you should not combine either with another GLP-1 agonist.6U.S. Food and Drug Administration. FDA Approves New Medication for Chronic Weight Management7Eli Lilly and Company. Open Letter Regarding Use of Mounjaro and Zepbound
What About the Cost to You
Zepbound’s list price runs between roughly $499 and $1,086 per monthly fill depending on the dose. State Medicaid programs receive mandatory federal rebates that substantially reduce the net cost, and TennCare covers the drug as a pharmacy benefit once the prior authorization is approved.8Eli Lilly and Company. Zepbound Pricing Information
In December 2025, Eli Lilly announced a program allowing patients on Medicare and Medicaid to buy Zepbound directly without insurance for $350 per month starting in 2026, with a stated goal of reaching $250 per month within two years. That is a cash-pay option outside the TennCare benefit, not a substitute for it.9Forbes. Eli Lilly Lowers Weight Loss Drug Zepbound Prices After Trump Deal
Other Weight-Loss Drugs TennCare Covers
If Zepbound is not right for you, TennCare’s obesity drug list has other options at different access tiers:
- Preferred, no prior authorization needed: benzphetamine, diethylpropion, Lomaira, orlistat, phendimetrazine, phentermine, and phentermine/topiramate.
- Preferred, prior authorization required: Wegovy (semaglutide) and Zepbound (tirzepatide).
- Non-preferred, prior authorization plus step therapy: Evekeo, Imcivree, and Saxenda. These require documented trial and failure of two preferred agents first.2OptumRx / TennCare. Provider Notice – Obesity Management Agents
If you already have a TennCare prescriber, the next step is to ask whether you meet the BMI and comorbidity criteria and, if so, to have their office submit the Obesity Management Agents PA form to OptumRx.