Fidelis Care does not cover Zepbound for weight loss on most of its plans. The drug is absent from the formularies for the Essential Plan, Ambetter Qualified Health Plans, and Child Health Plus, and New York Medicaid (which administers the Fidelis Medicaid pharmacy benefit through NYRx) excludes drugs prescribed for weight loss entirely. The one meaningful pathway for Fidelis members is a federal Medicare demonstration launching July 1, 2026, which operates outside the normal plan benefit. For commercial plans, a formulary exception request is the route to try.
Why Zepbound Is Treated Differently From Mounjaro
Zepbound and Mounjaro share the same active ingredient, tirzepatide, but Zepbound is FDA-approved for chronic weight management and moderate-to-severe obstructive sleep apnea in adults with obesity, while Mounjaro is approved for type 2 diabetes. Fidelis Care’s internal GLP-1 policy categorizes Mounjaro under “Diabetes” and Zepbound under “Obesity,” and states plainly that “treatment of obesity is an excluded benefit for many plans.”1Fidelis Care. GLP-1 Agonist Policy That split explains why a member can sometimes get tirzepatide covered as Mounjaro for diabetes but not as Zepbound for weight loss.
Coverage by Fidelis Plan
Fidelis Medicaid Managed Care and HARP
Pharmacy benefits for Fidelis Medicaid and HARP members run through NYRx, New York’s Medicaid pharmacy program. NYRx does not cover drugs prescribed for weight loss and specifically names Wegovy, Ozempic, Qsymia, and Mounjaro as not covered when prescribed for that purpose.2eMedNY. NYRx Pharmacy Benefits Zepbound falls in the same bucket. Mounjaro can be covered through NYRx only when the prescription is for type 2 diabetes.
A pending bill, S5798, would require New York Medicaid to cover FDA-approved chronic weight management drugs for adults with obesity and at least one weight-related condition. As of early 2026 it remains in the Senate Health Committee.3New York State Senate. Senate Bill S5798
Essential Plan
The Essential Plan formulary, updated April 2026, does not list Zepbound or tirzepatide, and the anti-obesity section contains no GLP-1 medications.4Fidelis Care. Essential Plan Formulary A formulary exception request is possible but reviewed under clinical criteria described below.
Ambetter from Fidelis Care (Qualified Health Plans)
The Ambetter QHP formulary, updated June 2026, also does not list Zepbound. It is treated as non-formulary rather than excluded, which keeps the exception process open. The QHP formulary does cover some older anti-obesity drugs: phentermine at Tier 1 with prior authorization, phentermine-topiramate at Tier 1 with a quantity limit and prior authorization, and Contrave at Tier 3 with a quantity limit and prior authorization.5Fidelis Care. QHP Formulary Showing a failed trial of one of these can support an exception request for Zepbound.
Child Health Plus
The Child Health Plus formulary dated June 2026 includes no GLP-1 medications for weight management.6Fidelis Care. Child Health Plus Formulary Zepbound is FDA-approved only for adults, so this plan would not typically apply.
Wellcare by Fidelis Care Medicare Advantage
Federal law blocks standard Part D plans from covering drugs prescribed specifically for weight loss, so Zepbound is not available for weight management through the usual Wellcare Part D benefit. If Zepbound is prescribed for moderate-to-severe obstructive sleep apnea, the weight-loss exclusion does not apply, and a standard formulary exception request may be considered.7CMS. Medicare GLP-1 Bridge
The Medicare GLP-1 Bridge Program
The Centers for Medicare and Medicaid Services launched a demonstration that provides access to Zepbound (KwikPen), Wegovy, and Foundayo for eligible Medicare beneficiaries from July 1, 2026, through at least the end of the year.7CMS. Medicare GLP-1 Bridge Beneficiaries in eligible Part D plans, including Medicare Advantage plans like Wellcare by Fidelis Care, who meet BMI and health-condition criteria can get Zepbound at a fixed $50 monthly copayment. That cost does not count toward Part D deductibles or out-of-pocket limits.
The Bridge program runs outside normal plan administration. A single central processor (Humana) handles prior authorization, claims, and pharmacy payments, so Fidelis Care is not directly managing the benefit.8Medicare Rights Center. GLP-1 Weight Loss Drug Demonstration Begins July 2026 Wellcare members who think they qualify should ask their prescriber to submit through the Bridge channel rather than through the plan’s standard pharmacy benefit.
Requesting a Formulary Exception or Appealing a Denial
For commercial Fidelis plans where Zepbound is non-formulary, the prescriber submits a Medication Request Form, available on the Fidelis Care website or by calling Member Services at 1-888-343-3547.9Fidelis Care. Provider Pharmacy Information Fidelis will consider authorizing a non-formulary drug when the prescriber documents one of three things: an allergic or adverse reaction to a preferred medication, failure of preferred alternatives, or a medical condition that makes switching to a preferred drug inadvisable.5Fidelis Care. QHP Formulary All GLP-1 products require prior authorization where coverage exists, and Fidelis has said it reviews these requests to confirm FDA-approved indications.10Fidelis Care. GLP-1 Agonist Provider Information
Fax numbers for initial pharmacy requests differ by plan: Medicare uses 844-235-5021; Child Health Plus, Essential Plan, and Ambetter use 844-235-4852. Appeals go to 866-388-1766 for Medicare and 888-865-6531 for the other three.9Fidelis Care. Provider Pharmacy Information
Medicare members who are denied have 65 days to file an appeal through Wellcare by Fidelis Care, by phone at 1-800-247-1447, by fax at 1-877-533-2402, or by mail. An expedited appeal, used when the standard timeline could jeopardize health, must be decided within 72 hours. Denied appeals are automatically forwarded to an Independent Review Entity.11Fidelis Care. Wellcare by Fidelis Care Rights, Appeals, and Disputes
Paying for Zepbound Without Coverage
Eli Lilly’s Self Pay Journey Program through LillyDirect offers single-dose vials at $299 per month for 2.5 mg, $399 for 5 mg, and $449 for 7.5 mg through 15 mg, provided refills are picked up within 45 days of the prior prescription. Vials require administration with a needle and syringe rather than a pen injector. A separate Lilly savings card can bring the cost as low as $25 per month for commercially insured patients.12Eli Lilly. Zepbound Coverage and Savings
Anyone enrolled in a government-sponsored plan, including Medicare, Medicaid, TRICARE, or VA benefits, is not eligible for the Lilly savings card or the self-pay program. That rules out Fidelis Medicaid and Wellcare Medicare members. All current Lilly savings programs expire December 31, 2026.12Eli Lilly. Zepbound Coverage and Savings
The Lilly Cares Foundation Patient Assistance Program does not include Zepbound, and the PAN Foundation’s obesity fund was not accepting new applications as of mid-2026.13GoodRx. Zepbound Cost Information