Environmental products can contribute to livelihoods through support of current consumption and provision of an economic safety net. But what is their role in lifting households out of poverty? Here we investigate the absolute and relative economic importance of commercial medicinal plants, including the high-value Chinese caterpillar fungus (Ophiocordyceps sinensis), to rural livelihoods in the high mountains of Nepal. We assess their role in providing a household-level pathway out of poverty. Data are derived from a structured household survey (n = 72) conducted in Jumla District and covering a 9-year period (2006–2015), supplemented with key informant interviews. We found that income from selling wild-collected medicinal plant products constituted an average of 58% of the total annual household income and 78% of cash income. Medicinal plant income increased in the observation period—even though medicinal plant income per collection day decreased, income at the community level doubled. We argue that medicinal plant commercialization is a rare opportunity to increase locally derived and controlled incomes with a range of positive outcomes, such as supporting livelihood strategies and mitigating the negative effects of outmigration.