News  CVS Caremark decides to remove Zepbound from CVS Caremark formulary

Why is coverage for Zepbound being removed as of July 1, 2025? 

All Group insurance Commission (GIC) non-Medicare health insurance plans provide you with prescription drug coverage that is administered by CVS Caremark. CVS Caremark utilizes a formulary to help the GIC manage costs while making sure that our members have access to clinically appropriate medications. 

CVS Caremark’s formulary is updated on a quarterly basis, which allows the GIC and others to accommodate new drugs that have come on the market, patent expirations, the introduction of lower cost generic and biosimilar drugs, and/or changes in federal guidance and negotiations that can lead to cost savings for the plan. As a result of these changes, new drugs are added to the formulary, some are removed, and some drugs change tiers. These changes are announced a few months prior to the effective date and communicated to those impacted and to the provider community, to allow those affected to prepare for the changes.   

There is an increased demand and rising costs for GLP-1 medications, which are the fastest-growing medication segment, significantly contributing to the GIC’s overall pharmacy spending. These challenges are only expected to rise with new approvals and increased member demand. 

CVS Caremark’s decision to remove Zepbound from the CVS Caremark formulary, effective July 1, 2025, is not intended to reduce access to these medications, but rather to reasonably balance access and affordability. Leveraging formulary design to lower the cost of weight loss treatments is designed to enable the GIC and other plans that utilize CVS Caremark to keep these obesity treatments available as a covered benefit. Many employers and insurance companies have stopped covering GLP-1's altogether as a result of the increased expenditures while the GIC continues to cover them at this time.

Can I change to a different medical plan that covers Zepbound, since this change was announced after annual enrollment?

No, all GIC medical plans have the same prescription benefits administered by CVS Caremark for non-Medicare plans, and CVS SilverScript formulary for Medicare members. Changes to the formulary, similar to changes to an insurance carrier’s provider network, are not a qualifying event allowing for a change of medical plan or to cancel or drop coverage.

Is the covered formulary alternative similar to Zepbound?

Yes, both Wegovy and Zepbound are GLP-1 medications that have been shown to support weight loss. Although the way these medications work in the body is slightly different, they are both considered highly effective for weight loss with similar side effect profiles. It is important to remember that the health benefits of these medications are attributed to achieving a healthy weight and maintaining that weight loss over time. 

As of July 1, 2025, Wegovy will be the preferred formulary option for obesity treatment. Prescribers and members using Zepbound should have received notification from CVS Caremark about this change. Other formulary options in this category include orlistat, Qsymia and Saxenda.

What if I already tried Wegovy and did not achieve sufficient weight loss or experienced intolerable side effects?

If you have previously tried Wegovy and either experienced severe or intolerable side effects or did not achieve sufficient weight loss, you may request a formulary exception to be covered for a different weight loss drug through CVS Caremark. You or your provider may initiate an exception request for Zepbound as early as June 16th to avoid disruption. This exception process allows for a case-by-case medical necessity review to determine whether coverage for tirzepatide (Zepbound or Mounjaro) is appropriate based on your clinical circumstances. 

The review will consider clinical history/response to prior treatment and will require supportive documentation from your provider. If the formulary exception request is approved, the requesting member will be allowed to continue on tirzepatide. There are two formulations of tirzepatide available in the marketplace today, both manufactured by the same company in the same dose and strength but with two different brand names (Mounjaro and Zepbound).  Members with diabetes who currently take the Mounjaro formulation of tirzepatide will not experience any disruption.

If I switch from Zepbound to Wegovy, will I need to go through a Prior Authorization process again? 

No, members with an active prior authorization for Zepbound will not need to obtain a new prior authorization if they move to Wegovy. Existing overrides will be transitioned for all members to ensure they have access to Wegovy without repeating this process. Zepbound approvals will expire on their original end date and, at that time, members will need to submit a new prior authorization request for continued coverage for Wegovy.

Can you elaborate more on the clinical results of Zepbound vs Wegovy?

While controlled clinical trials may show Zepbound to be more effective for weight loss, real world evidence suggests that they are comparable in actual use. It is important to remember that the health benefits of these medications are not tied to losing the largest amount of weight possible, but helping members to achieve a healthy weight and maintain that weight loss over time. If a member is unable to achieve sufficient weight loss with Wegovy, the exception process, which may provide coverage for tirzepatide (Zepbound or Mounjaro), is available1.

Will Zepbound be removed from coverage for Obstructive Sleep Apnea indication?

Yes. While Zepbound is approved for obstructive sleep apnea (OSA), studies indicate that the mechanism for improving OSA is attributed to weight loss, indicating that weight loss by any effective method is also appropriate to treat OSA. There are also studies that demonstrate Wegovy’s direct effectiveness in treating OSA, although it has not been approved for this purpose by the FDA at this time2.

Will prior authorizations for Zepbound that have been approved for Obstructive Sleep Apnea (OSA) remain in place or will members be required to try Wegovy?

All existing prior authorizations for Zepbound will transition to Wegovy, including those approved for individuals with moderate-to-severe OSA. All members, regardless of indication, will need to have tried and failed Wegovy before they can access tirzepatide. The mechanism for improving OSA is attributed to weight loss indicating that weight loss by any effective method is also appropriate to treat OSA2.

What about GLP-1 coverage for cardiovascular (CV) risk reduction?

Semaglutide (Wegovy) is currently the only drug in this class with FDA approval to reduce the risk of major CV events—such as heart attack, stroke and cardiovascular death in adults with established heart disease. 

Clinical trials have shown that these benefits occur even before patients reach target doses or experience significant weight loss. Cardiovascular outcomes for tirzepatide (Zepbound) are still under investigation.

How does a member/prescriber request a formulary exception review?

Members may contact CVS Customer Care at 877-876-7214 to request that a formulary exception form be sent to their prescriber. However, only the prescriber may submit the required clinical documentation to initiate the exception review process. The request can be submitted by the prescriber via fax or, where available, through electronic prior authorization (ePA) beginning June 16, 2025.

To initiate a formulary exception request directly, providers may also call 855-240-0536. Exception requests will be reviewed based on established clinical criteria, and the prescriber must provide supporting documentation such as chart notes or laboratory test results. 

Both members and prescribers will be notified of the decision. 

If an exception is approved for Zepbound, the member will be responsible for paying the tier 3 copay. For Mounjaro, members will still be charged the tier 2 copay.

If an exception is denied, the notice will include instructions on how to appeal, including the deadline and what information is required. 

My exception request was denied. Can I still get Zepbound without a prior authorization?

Yes. You may still fill a prescription for Zepbound, but you will be responsible for the full cost of the drug.

For those members who are currently taking Zepbound and will be transitioning over to Wegovy, are there any considerations for determining what's the appropriate dosage of the new drug?

The appropriate Wegovy dose when transitioning from Zepbound depends on where the member is in their treatment journey. Both drugs require titration—starting low and increasing as tolerated—so the starting dose of Wegovy will vary by individual.

There’s a helpful conversion chart available to guide dose equivalency, and prescribers receive notifications listing all product strengths to support informed decisions. Ultimately, the choice of dose is up to the provider, as clinical data on direct transitions is limited.

Is there more detail on the exceptions process?

Initiating an Exception for a Non-Formulary Drug

• Who can initiate an exception request?
  • Member: The member can initiate the request by contacting CVS Customer Care line for GIC members at 877-876-7214 and request that a formulary exception form be sent to their prescriber.
    • CVS’s PA department will then reach out to the prescribing physician via fax or through electronic PA (ePA) with the exception criteria.
  • Prescribing Physician: A prior authorization may be initiated by phone call, fax, electronic request, or in writing to CVS Caremark by a member’s prescribing physician or their representative.
    • Phone Number for providers to initiate the formulary exception: 855-240-0536
    • Fax Number for completed prior authorization Form: 1-888-487-9257
• Exception Completion by Prescribing Physician/Review Process:
  • The exceptions fax form or ePA is completed by the member’s physician and returned to the Exceptions department for review. 
  • The exception request is reviewed against the supporting criteria. 
    • The review will consider if the member has previously filled a prescription for Wegovy. 
      1. If the member has not previously tried Wegovy and the prescriber indicates that the member can be treated with Wegovy, then the prescriber will be prompted to submit a new prescription for Wegovy if not already on file.
      2. If the member has previously tried and failed Wegovy, or if the member is unable to take Wegovy (e.g., intolerance, contraindication), then the prescriber must submit documentation showing the inadequate treatment response or contraindication. Documentation can include chart notes or a letter for medical necessity.
         • Failure means the member was able to tolerate Wegovy, but experienced an inadequate treatment response when taking the medication.
    • In addition to the Wegovy requirement above, the prior authorization factors and quantity limits currently in place today are still applicable. 
      1. If the indication for use is weight management, then:
         • The member must have participated in a comprehensive weight management program for at least 6 months prior to therapy and the drug must be used with a reduced-calorie diet and increased physical activity. 
         • Documentation must be submitted that shows the individual’s Body Mass Index (BMI) or current height and weight to calculate BMI. 
           • If the request is for continuation of therapy, then the documentation must show that the member has lost at least 5% of baseline body weight or has continued to maintain their initial 5% weight loss. This could include the individual’s current height and weight as well as weight prior to starting therapy.
      2. If the indication for use is Obstructive Sleep Apnea, then:
         • The medication must be used with a reduced-calorie diet and increase physical activity.
         • Documentation must be submitted that shows the member’s current BMI.
         • Documentation must show that the member has an established diagnosis of moderate to severe OSA. This is determined by Apnea-Hypopnea Index (AHI) on polysomnography or home sleep apnea test.
  • If the exception is approved, then the prior authorization department enters the applicable override into the CVS Caremark authorization system to allow coverage of tirzepatide. A test claim is processed to ensure the claim will pay when the member fills the prescription at the pharmacy.

References:

₁Drugs February 17, 2025. https://www.drugs.com/medical-answers/tirzepatide-semaglutide-how-compare-3576410/

₂Aronne LJ, Wadden TA, Lewin A, et al. Tirzepatide as Compared with Semaglutide for the Treatment of Obesity. N Engl J Med. 2025;392:1945-1958. doi: 10.1056/NEJMoa2416394.