CVS Caremark announces the Zepbound formulary removal, producing the year's largest forced-switching query spike

CVS Caremark, one of the largest US pharmacy benefit managers, decided to remove Zepbound (tirzepatide) from its formulary effective July 1, 2025, and make Wegovy (semaglutide) the preferred covered option for obesity treatment ^[1]. For patients whose employer or plan uses the CVS Caremark template formulary, the practical effect was a forced switch, an exception request, or paying cash — and search interest in exactly those three paths spiked harder than for any clinical news in this category this year.

The clearest public explanation came from the Massachusetts Group Insurance Commission (GIC), which covers state and municipal employees and whose non-Medicare drug benefit is administered by CVS Caremark ^[1]. The GIC said the formulary is updated quarterly and that GLP-1 drugs are "the fastest-growing medication segment," contributing significantly to overall pharmacy spending ^[1]. It framed the removal as a way to "reasonably balance access and affordability" so that obesity drugs stay covered at all, noting that many employers and insurers have stopped covering GLP-1s entirely ^[1].

What changes for people on Zepbound

Members with an active prior authorization for Zepbound did not need a new prior authorization to move to Wegovy; existing overrides were transitioned automatically ^[1]. Zepbound approvals expire on their original end date, after which a new prior authorization is required for continued Wegovy coverage ^[1].

The change also applied to Zepbound's obstructive sleep apnea indication. The GIC said all existing Zepbound prior authorizations, including those approved for moderate-to-severe OSA, transition to Wegovy, and that all members "regardless of indication" must have tried and failed Wegovy before accessing tirzepatide ^[1]. Wegovy is not FDA-approved for OSA ^[1].

People who already tried Wegovy and had intolerable side effects or insufficient weight loss could request a formulary exception. Prescribers could start submitting requests as early as June 16, 2025, by fax or electronic prior authorization ^[1]. Members could call CVS Customer Care at 877-876-7214 to have a form sent to their prescriber, but only the prescriber can submit the clinical documentation ^[1]. Providers could initiate requests at 855-240-0536 ^[1].

If an exception is approved, the member pays the tier 3 copay for Zepbound, or the tier 2 copay for Mounjaro ^[1]. If it is denied, the denial notice includes appeal instructions and deadlines, and the member can still fill Zepbound while paying the full cost ^[1]. People with diabetes taking Mounjaro were not affected ^[1].

Other covered options in the category include orlistat, Qsymia and Saxenda ^[1]. Notably, a formulary change is not a qualifying event, so GIC members could not switch health plans in response — all GIC medical plans use the same CVS Caremark pharmacy benefit ^[1].

Why it matters for patients

This is a coverage decision, not a safety decision. CVS Caremark's position, as relayed by the GIC, is that 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" ^[1]. The GIC also pointed out that semaglutide (Wegovy) is the only drug in the class with FDA approval to reduce the risk of major cardiovascular events in adults with established heart disease, while cardiovascular outcomes for tirzepatide remain under investigation ^[1].

Switching is not a simple one-for-one swap. Both drugs require titration, the appropriate starting Wegovy dose "depends on where the member is in their treatment journey," and the GIC acknowledged that "clinical data on direct transitions is limited" ^[1]. A conversion chart exists to guide prescribers, but the dose choice is up to the provider ^[1].

There is also paperwork attached to continued coverage. Standard prior authorization criteria still apply: for weight management, documented participation in a comprehensive weight management program for at least six months, BMI documentation, and, for continuation, proof of at least 5% loss of baseline body weight or maintenance of that loss ^[1].

What happens next

• June 16, 2025: exception requests could begin, timed to avoid a coverage gap ^[1].
• July 1, 2025: Zepbound comes off the CVS Caremark formulary and Wegovy becomes the preferred obesity option ^[1].

How many people were affected nationally, and how many exception requests were approved or denied, is not stated in the available source.