Yes, NYSHIP does cover Zepbound in 2026 through the Empire Plan, but the prescription requires prior authorization and the patient must meet specific clinical criteria. Zepbound (tirzepatide) appears on the 2026 Empire Plan Advanced Flexible Formulary under anti-obesity agents, alongside Wegovy, Contrave, and liraglutide, and all four carry the same authorization requirement.1NYS Department of Civil Service. 2026 Empire Plan Advanced Flexible Formulary Preferred Drug List
Being on the formulary is not the same as automatic coverage. Empire Plan documents note that the drug list “is not all-inclusive and does not guarantee coverage,” and enrollees are directed to verify benefits at empireplanrxprogram.com or by calling 1-877-7-NYSHIP (1-877-769-7447), option 4.2NYS Department of Civil Service. Empire Plan Advanced Flexible Formulary Documents
Who Qualifies Under the Prior Authorization Criteria
CVS Caremark manages the Empire Plan’s prescription benefit and publishes the clinical criteria the prescriber has to satisfy. For Zepbound used for weight management, three things must be documented:
- A body mass index of 30 or higher, or a BMI of 27 to 29.9 with at least one weight-related condition such as hypertension, type 2 diabetes, or high cholesterol.3CVS Caremark. Zepbound Prior Authorization Clinical Criteria (6192-C)
- Participation in a comprehensive weight management program — behavioral modification, a reduced-calorie diet, and increased physical activity — for at least six months before starting drug therapy.4CVS Caremark. Zepbound Prior Authorization Criteria (6947-C)
- Use alongside a reduced-calorie diet and increased physical activity going forward.
There is a separate pathway for moderate to severe obstructive sleep apnea. The patient needs a confirmed OSA diagnosis with an apnea-hypopnea index of at least 15 events per hour and a current BMI of 30 or above.4CVS Caremark. Zepbound Prior Authorization Criteria (6947-C)
How Long an Approval Lasts
Approval is not indefinite. For weight management, the initial authorization runs eight months. To continue coverage, the patient must have completed at least three months at a stable maintenance dose and lost at least 5% of baseline body weight, or maintained a prior 5% loss. Continuation approvals then run 12 months. OSA approvals start at six months, with 12-month renewals contingent on a positive treatment response.3CVS Caremark. Zepbound Prior Authorization Clinical Criteria (6192-C)
Getting the Authorization Submitted
The prescriber handles the paperwork, not the patient. Documentation must reach the plan before the prescription is filled, and both the doctor and the patient are notified of the decision.5UnitedHealthcare. NY Empire Plan Predetermination Form To check on the status of a request under the prescription drug benefit, enrollees can call 1-877-7-NYSHIP and choose option 4.6NYS Department of Civil Service. Empire Plan Prior Authorization and Specialty Quantity Limit Drug List, April 2026
What You Will Pay at the Pharmacy
The Empire Plan uses a three-tier copay structure at network pharmacies. For a 30-day supply, copays are $5 for generic drugs (Level 1), $30 for preferred brand-name drugs (Level 2), and $60 for non-preferred brand-name drugs (Level 3). A 90-day supply doubles those: $10, $60, and $120. Mail-order and specialty pharmacy 90-day copays run slightly lower, at $5, $55, and $110.7Putnam County. 2026 Summary of Benefits Comparison, Empire and MVP
The published 2026 drug list does not explicitly label Zepbound preferred or non-preferred, so enrollees should confirm their exact copay at empireplanrxprogram.com or by phone.1NYS Department of Civil Service. 2026 Empire Plan Advanced Flexible Formulary Preferred Drug List The prescription drug out-of-pocket maximum for 2026 is $1,494 for individual coverage and $2,977 for family coverage. Those limits do not apply to enrollees or dependents for whom Medicare is primary.8NYS Department of Civil Service. Empire Plan At a Glance, 2026
If the Prior Authorization Is Denied
A denial letter spells out appeal rights and the process for filing. Members can also call the number on their prescription ID card for guidance.9Express Scripts. What If My Coverage Review Is Denied Separately, enrollees can request a formulary exception, in which the prescriber explains the medical rationale for the specific drug. A decision typically comes within 72 hours, or within 24 hours for expedited requests.10SilverScript/Empire Plan. Empire Plan Medicare Rx 2026 Formulary While the appeal is pending, options include asking the prescriber about a covered alternative or paying the retail price out of pocket.
Why the Lilly Savings Card Will Not Work
Lilly’s savings programs can bring Zepbound down to as little as $25 per fill for commercially insured patients whose plan covers the drug, and to around $499 per month for the uninsured.11Lilly. Zepbound Savings These programs exclude anyone enrolled in a “state, federal, or government funded healthcare program.”12Lilly. Zepbound HCP Coverage and Savings
NYSHIP is a state-funded plan for New York public employees and retirees, so its enrollees are ineligible. Anyone who begins receiving drug coverage through a government program while using a Lilly savings card is required to notify Lilly and stop using it.12Lilly. Zepbound HCP Coverage and Savings Lilly’s separate KwikPen Self-Pay Savings Card starts at $299 per month for the lowest dose, but patients who use it cannot seek reimbursement from any third-party payer, including their insurance.11Lilly. Zepbound Savings
A Note for NYSHIP HMO Enrollees
Everything above applies to the Empire Plan, NYSHIP’s statewide indemnity option. NYSHIP also offers HMO options such as EmblemHealth, and each HMO maintains its own formulary and authorization rules.13EmblemHealth. New York State Insurance Program Tier 2 Rx Formulary 2026 If you are enrolled in an HMO through NYSHIP, check that plan’s formulary or call its member services to confirm whether Zepbound is covered and what steps apply.