CVS Caremark holds GLP-1 formulary steady for 2026, keeping Wegovy preferred
People whose pharmacy benefits run through CVS Caremark will likely find Wegovy covered first for weight loss, while Zepbound requires an exception that starts with a documented Wegovy trial.
CVS Caremark is keeping its GLP-1 coverage rules unchanged for 2026, with Wegovy (semaglutide) preferred and Zepbound (tirzepatide) excluded on its main commercial drug lists [1][2]. The company, a pharmacy benefit manager rather than an insurer, confirmed there would be "no new GLP-1 formulary changes" for January 2026 [1].
The exclusion dates to July 1, 2025, when CVS Caremark removed Zepbound from three formularies: Standard Control, Advanced Control and Value [1][2]. Those are the lists used by most employers [1]. The change was estimated to affect about 200,000 patients [1]. Wegovy sits at tier 2 or 3 depending on the plan, while Zepbound has no tier because it is not covered [1][2].
Coverage is not identical across plans. Self-funded employers can negotiate their own terms, and some have opted out of the Zepbound exclusion, so a plan's actual drug list may differ from the standard version [1]. CVS Caremark manages pharmacy benefits for more than 75 million plan members and processes roughly 27 percent of U.S. prescription claims [2]. GoodRx research cited in one coverage guide estimates that more than 100 million Americans lack commercial insurance coverage for Zepbound as of 2026 [1].
Other GLP-1 drugs are unchanged on the standard lists. Ozempic (semaglutide) and Mounjaro (tirzepatide) remain covered at tier 2 for type 2 diabetes [1][2]. The two sources disagree about Saxenda (liraglutide), a weight-loss drug: one lists it as limited at tier 3 [1], the other as covered at tier 2 [2].
Zepbound patients on a CVS Caremark-managed plan can request a formulary exception. One guide describes the requirements as a documented trial of Wegovy lasting 12 to 16 weeks that shows less than 5 percent weight loss, or documented intolerance to Wegovy; a BMI of 30 or higher, or 27 or higher with a related condition such as diabetes, high blood pressure or sleep apnea; and a letter of medical necessity from the prescriber [1].
Wegovy itself generally requires prior authorization even though it is preferred. Typical criteria include BMI thresholds, participation in a six-month weight management program, chart notes documenting BMI and related conditions, and no contraindications such as a personal or family history of medullary thyroid cancer or MEN2 [2]. Denials can be appealed within 180 days [1][2]. One source says commercial insurance appeals succeed more than 65 percent of the time [2]; the other says more than 80 percent of Medicare Advantage prior authorization appeals succeed [1].
In September 2025, two class actions were filed by Zepbound patients: Larkin v. CVS Caremark (Sept. 3, 2025, S.D.N.Y., Case No. 1:25-cv-07307) and Hamburger v. CVS Caremark (Sept. 4, 2025, D.D.C.) [1][2]. The plaintiffs allege CVS prioritized rebate revenue over patient outcomes by steering Zepbound patients to Wegovy. CVS Caremark has called the lawsuits "without merit" [1][2].
Why it matters for patients
If a prescription card shows CVS Caremark, the first weight-loss GLP-1 a plan covers is likely Wegovy, not Zepbound. For people already taking Zepbound, that can mean switching drugs, paying out of pocket, or going through a formulary exception and possible appeal. The process can take months, and an exception generally requires evidence that Wegovy was tried first or was not tolerated [1].
Some plans offer a $200 monthly copay option for GLP-1 weight-loss drugs where no coverage existed before. One guide compares that with self-pay options such as about $346 a month through TrumpRx.gov and $299 to $449 a month through LillyDirect [1]. Formulary terms can differ from the standard lists, so the plan document and the employer's benefits office are where specific drug coverage and tier placement get confirmed [1][2].
It has not been reported whether CVS Caremark will revisit its GLP-1 lists for 2027, or how the pending lawsuits might affect future formulary decisions.
Sources
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