CVS Caremark, a prominent pharmacy benefit manager (PBM) and a subsidiary of CVS Health Corp., plays a crucial role in the prescription drug supply chain. As a negotiator between pharmacies, insurers, and drug manufacturers, CVS Caremark influences medication costs, accessibility, and network participation. Recent decisions regarding the coverage of GLP-1 receptor agonists, such as Ozempic and Zepbound, have sparked considerable discussion among patients, healthcare providers, and pharmaceutical companies.
Understanding CVS Caremark's Role
Pharmacy benefit managers (PBMs) like CVS Caremark negotiate drug prices and determine which medications are covered under various insurance plans. These negotiations significantly impact the cost of drugs for consumers and the profitability of pharmaceutical manufacturers. Pharmaceutical giants have been critical of PBMs, saying their role needs to change because consumers is if "intermediaries take less for themselves."
Current Coverage of GLP-1 Medications
As of 2024, CVS Caremark's standard formulary includes several GLP-1 medications for weight management and type 2 diabetes.
For weight management:
- Saxenda
- Wegovy
- Zepbound
For type 2 diabetes:
- Ozempic
- Mounjaro
However, coverage for these medications often requires prior authorization to ensure medical appropriateness. These drugs are typically placed in higher tiers, meaning they may be considered non-preferred, and patients might need to try other medications first (step therapy).
CVS Caremark generally covers GLP-1s for weight management when a patient has a BMI of 30 or higher, or a BMI of 27 or higher with a confirmed diagnosis of at least one weight-related condition such as hypertension, type 2 diabetes mellitus, dyslipidemia, cardiovascular disease, or obstructive sleep apnea. Coverage for Ozempic or Mounjaro is typically provided for patients with a confirmed diagnosis of type 2 diabetes.
Read also: Benefits of couples massage detailed
Changes in Formulary and Impact on Patients
CVS Caremark's decisions to alter its formulary can have significant implications for patients. For instance, the removal of coverage for certain drugs can disrupt treatment plans and force patients to switch medications.
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."
McGowan 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. This goes beyond CVS Caremark, according to McGowan, who 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."
The Case of Zepbound
Zepbound (tirzepatide), manufactured by Eli Lilly, was approved by the FDA in 2023 for chronic weight management in adults with obesity or overweight with weight-related medical problems. Clinical trials demonstrated that participants using Zepbound experienced significant weight loss, sometimes exceeding that of Wegovy users.
Read also: How digestive health affects weight loss
However, CVS Caremark's decision to remove Zepbound from its formulary for some patients has raised concerns. According to Blando, removing coverage of the drug 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.
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."
Medical Necessity Exceptions
Despite formulary changes, CVS Caremark offers exceptions for drugs deemed medically necessary. These exceptions are reviewed on a case-by-case basis. Patients who believe they require a specific medication, even if it is not on the formulary, can request a medical necessity review from their insurance provider.
Eli Lilly told FOX Business that the company is committed to ensuring patients have access to the treatment they need. "While not all CVS Caremark plans are impacted, we’ve made robust efforts to proactively communicate with many of the patients who may be affected and provided clear next steps through our support programs," Lilly said in a statement, adding that the company is encouraging patients to speak with their healthcare providers about medical necessity exceptions or alternative coverage pathways.
Impact on Medicare and Aetna Plans
Individuals seeking Zepbound or Wegovy under Aetna’s Medicare plan will find that these weight loss medications are not covered through CVS Caremark. In fact, all prescriptions for weight management are likely to be denied coverage. However, Medicare does cover medications like Ozempic and Mounjaro for treating type 2 diabetes. To obtain prior authorization, your provider will likely need to include recent lab results and chart notes supporting your diabetes diagnosis.
Read also: Weight Loss Meds & BCBS
Appealing Coverage Denials
Patients have the right to appeal insurance denials of medication coverage. The denial letter typically outlines the reasons for the denial and the steps required to appeal. Common reasons for denial include:
- No proof of lifestyle modification
- No participation in a weight management program
- Failure to prove medical necessity
- Step therapy/preferred drugs
- Weight loss plan exclusion
It’s important to keep in mind that weight loss plan exclusion denials are notoriously difficult to fight. This is because a plan exclusion indicates your employer has chosen not to offer coverage for weight loss medications, and your PBM is unlikely to overstep that decision. With that said, it’s also possible for any of the above denial reasons to be overturned with a well-written appeal. Be sure to directly address your denial reason, include any pertinent medical or lifestyle information to help your case, and submit your appeal letter via the method outlined in your denial letter.
Changes in Diabetes Medication Coverage for 2025
CVS Caremark has switched up its diabetes coverage for 2025.
One notable change is the exclusion of the V-go Infusion Pump, an insulin delivery device that is worn like a patch and provides continuous subcutaneous insulin infusion. CVS Caremark instead prefers Omnipod products (Omnipod 5 and Omnipod Dash) or the Twiist infusion system.
The Twiist system was approved earlier this year and developed by a company cofounded by a former executive at CVS Health. Twiist was approved by the FDA in March 2024 and combines an automated insulin delivery with a continuous glucose monitoring (CGM) device for people ages 6 and up with type 1 diabetes. It uses Tidepool Loop technology, which enables the system to automatically adjust insulin delivery based on CGM readings and predicted glucose levels.
CVS Caremark also has removed several of Merck’s products that treat diabetes, including the older Janumet/Janumet XR (sitagliptin and metformin) and Januvia (sitagliptin). As an alternative for Janumet, CVS Caremark has suggested patients instead use Zituvimet (saxagliptin-metformin), another DPP-4 inhibitor, which the FDA approved in November 2023. Additionally, CVS has added to its national formulary saxagliptin, a generic of Onglyza, which is no longer available.
CVS Caremark has also added the unbranded biosimilar to Sanofi’s Lantus, which treats type 2 diabetes in adults and type 1 diabetes in both adults and children.
CVS Caremark is removing Novo Nordisk’s Victoza (liraglutide), one of the much-talked about glucagon-like peptide 1 (GLP-1) drugs, and instead listing a generic version that was approved this year. CVS Caremark is also suggesting that patients consider several other GLP-1s instead of Victoza, including Mounjaro (tirzepatide), Ozempic (semaglutide), Rybelsus (semaglutide) and Trulicity (dulaglutide).
Other Notable Formulary Changes
Beyond diabetes medications, CVS Caremark has made changes to its formulary for other conditions:
- HIV medications: Added Apretude (cabotegravir) for PrEP and Cabenuva (cabotegravir, rilpivirine) for HIV treatment.
- Breast cancer drugs: Added biosimilars Kanjinta and Trazimera to Herceptin (trastuzumab).
- Lung cancer drugs: Added Augtyro (repotrectinib).
- Central nervous system disorders: Including Zurzuvae (zuranolone) for postpartum depression and Abilify Asimtufii (aripiprazole) for bipolar disorder.
CalPERS and CVS Caremark Partnership
Effective January 1, 2026, CVS Caremark will replace OptumRx as the new pharmacy benefits manager (PBM) for the CalPERS health plans. CalPERS and CVS will work together to ensure a smooth transition for members, including a transition period for filling prescriptions no longer on the CVS formulary and an automatic transfer of approved prior authorizations.