CVS Caremark, a major pharmacy benefit manager (PBM), is making significant changes to its formulary regarding weight loss medications, impacting coverage for drugs like Zepbound and Wegovy. These changes, effective July 1, 2025, are driven by increasing demand and rising costs associated with glucagon-like peptide-1 (GLP-1) medications, the fastest-growing segment in the medication market. This article delves into the specifics of these changes, their implications for patients, and the broader context of the weight loss drug market.
Understanding the Formulary Change
CVS Caremark utilizes a formulary to manage costs and ensure members have access to clinically appropriate medications. The formulary is updated quarterly to accommodate new drugs, patent expirations, lower-cost generics, and changes in federal guidance. As part of a recent update, CVS Caremark has decided to make Novo Nordisk’s Wegovy the preferred GLP-1 medication for weight loss on its template formularies, starting July 1, 2025. This means Eli Lilly’s Zepbound will no longer be included in the formulary, except in cases of medical necessity.
The decision to prioritize Wegovy is intended to balance access and affordability, allowing CVS Caremark and other plans that utilize its services to continue offering obesity treatments as a covered benefit. According to Blando, removing coverage of Zepbound will result in an estimated client savings of 10% to 15% year over year in the anti-obesity medication space for its clients who choose to cover these medications for weight loss. 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.
Zepbound: A Promising Treatment
Zepbound, the brand name for Eli Lilly's tirzepatide, was approved by the FDA in 2023 for chronic weight management in adults with obesity or overweight with weight-related medical problems. Tirzepatide was already approved to treat type 2 diabetes and was sold under the brand name Mounjaro. It was widely viewed as a game-changer in the fight against obesity, after participants in a late-stage study lost up to a quarter of their body weight - making it more effective than Wegovy.
Despite its effectiveness, CVS Caremark is removing Zepbound from its formulary due to the "egregiously high list prices" for GLP-1 products set by drug manufacturers, which Blando says are "the single biggest barrier to patient access."
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Wegovy as the Preferred Alternative
As of July 1, 2025, Wegovy will be the preferred formulary option for obesity treatment. Wegovy (semaglutide 2.4 mg injection) is a GLP-1 medication manufactured by Novo Nordisk. Novo Nordisk’s Dave Moore stated, “We believe in the unique benefits of Wegovy and the difference this medicine can make for patients seeking treatment.” He added, “As the leader in obesity care for more than a decade, it is our responsibility to continue to work with others across the US health care system to find innovative opportunities to meet the needs of these patients and connect them with authentic, FDA-approved Wegovy in a convenient and affordable way.”
Novo Nordisk is expanding patient access to Wegovy injection 2.4 mg by enabling select telehealth providers to work directly through NovoCare Pharmacy to offer a simplified pathway for self-paying patients seeking access to authentic, FDA-approved Wegovy. CenterWell Pharmacy is the dispensing pharmacy managing prescription fulfilment and delivery for NovoCare Pharmacy, which is now allowing direct access to Hims & Hers Health, LifeMD, and Ro.
Impact on Patients
The formulary change will primarily affect patients currently taking Zepbound for weight loss. CVS Caremark has notified impacted members directly to ensure that IU medical plan members understand how these changes may affect their coverage. Existing prior authorizations for Zepbound will be automatically transferred to Wegovy, keeping the original expiration date.
However, gastroenterologist and obesity medicine specialist Dr. Christopher McGowan told FOX Business that CVS Caremark’s decision to drop coverage of the drug is "deeply disruptive for patients who are already stable and thriving on the medication." He highlighted that GLP-1 medications "are not interchangeable in practice, even if they appear similar on paper." He said switching medications "mid-journey can reverse hard-won progress.""For many, this isn’t just a simple substitution. It’s a high-stakes change that can affect long-term outcomes, trigger weight regain, or introduce new side effects," McGowan said.
Eli Lilly told FOX Business that the company is committed to ensuring patients have access to the treatment they need. Lilly is encouraging patients to speak with their healthcare providers about medical necessity exceptions or alternative coverage pathways and has made robust efforts to proactively communicate with many of the patients who may be affected and provided clear next steps through our support programs
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Medical Necessity Exceptions
There will still be exceptions to the formulary change if Zepbound is deemed a "medical necessity." That exemption will be reviewed "on a case-by-case basis," according to Blando.
If a patient has previously tried Wegovy and either experienced severe or intolerable side effects or did not achieve sufficient weight loss, they 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.
How to Request a Formulary Exception
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.
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Considerations for Transitioning to Wegovy
For those members who are currently taking Zepbound and will be transitioning over to Wegovy, 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.
Prior Authorization for Obstructive Sleep Apnea (OSA)
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 time.
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 OSA.
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.
The Role of PBMs
CVS Caremark is a subsidiary of CVS Health Corp., which also owns CVS Pharmacy. As a pharmacy benefit manager, CVS Caremark essentially acts as a negotiator between pharmacies, insurers and drug manufacturers within the prescription drug supply chain. PBMs negotiate with drug manufacturers and pharmacies to decide how much medicines cost, which drugs people can get and which pharmacies are part of their network.
Pharmaceutical giants have been critical of PBMs, saying their role needs to change. consumers is if "intermediaries take less for themselves." McGowan is concerned that its decision with Zepbound "underscores a troubling trend" in which "financial contracts between benefit managers and drug manufacturers are increasingly shaping clinical decisions." This means patients with fewer choices not because of what’s best for their health, but because of behind-the-scenes rebate deals, he continued.
Market Implications
Caremark’s decision could be the catalyst for Wegovy’s continued dominance amongst other GLP-1s, according to a Novo Nordisk news release. After the announcement, Eli Lilly’s stock closed at an 11% loss, according to CNBC.
With Novo Nordisk’s launch of NovoCare Pharmacy earlier this year-a direct-to-consumer program for shipping Wegovy straight to patients’ doors-the drug manufacturer is now partnering with CVS Caremark and its affiliated CVS pharmacies. While this new partnership may be leaving other weight-loss drugs at a loss, the collaboration is ultimately making some of the country’s most sought-after medications more accessible.
This announcement will almost certainly cause disruptions within the GLP-1 industry, and possibly the entire prescription drug market, as demand for these drugs continue to skyrocket. “A PwC survey in October 2024 found that 8% to 10% of Americans are currently taking GLP-1 drugs, and 30% to 35% of Americans are interested in using them,” continued Denise Myshko of Formulary Watch.