CVS Caremark holds its GLP-1 formulary steady for 2026

CVS Caremark has confirmed there are "no new GLP-1 formulary changes" for January 2026, meaning the pharmacy benefit manager's July 2025 decision to exclude Zepbound (tirzepatide) from its Standard, Advanced Control, and Value formularies remains in place ^[1]. Wegovy (semaglutide) stays the preferred GLP-1 medication for weight loss on those same lists ^[1][2].

The formulary structure has not changed since last July. Zepbound is excluded on the Standard Control, Advanced Control, and Value formularies, which are the ones most employers use ^[1][2]. Mounjaro (tirzepatide) and Ozempic (semaglutide), both approved for type 2 diabetes, remain covered at Tier 2 on these formularies, and Saxenda (liraglutide) has limited or covered status depending on the list ^[1][2]. CVS Caremark manages pharmacy benefits for more than 75 million plan members and handles about 27% of U.S. prescription claims, so its choices affect a large share of people using these drugs ^[2].

Not every plan follows the standard list. Self-funded employers can opt out of CVS Caremark's default formulary and negotiate their own coverage terms, so some employer plans still cover Zepbound even though it is excluded on the standard lists ^[1][2]. Some CVS Caremark plans have also introduced a $200-per-month copay option for GLP-1 weight loss drugs on plans that previously had no coverage at all, according to the source ^[1]. Patients are advised in the source material to check their ID card for a CVS Caremark reference and then call both their employer's HR department and the number on the card, since coverage can vary by plan design even under the same PBM ^[1][2].

The formulary change has also drawn legal challenges. In September 2025, two class action lawsuits, Larkin v. CVS Caremark in the Southern District of New York and Hamburger v. CVS Caremark in the District of Columbia, were filed alleging that CVS Caremark prioritized rebate profits over patient outcomes when it dropped Zepbound, and that Novo Nordisk, which makes Wegovy, pays larger rebates than Eli Lilly, which makes Zepbound ^[1][2]. The complaints estimate roughly 200,000 patients were affected, and include plaintiffs who say they lost significant weight on Zepbound, in one case 104.2 pounds with resolved sleep apnea, before facing a loss of coverage ^[1]. CVS Caremark has called the lawsuits without merit ^[1][2]. Separately, GoodRx research cited in the source material estimates that more than 100 million Americans lack commercial insurance coverage for Zepbound as of 2026, a sharp increase from prior years ^[1].

Why it matters for patients

For people currently on Zepbound through a CVS Caremark-managed plan, the continuation of the exclusion into 2026 means the options described since last July still apply: switch to Wegovy, seek a formulary exception, check whether an employer plan opted out of the exclusion, or pay out of pocket ^[1]. A formulary exception generally requires first trying Wegovy for 12 to 16 weeks with less than 5% weight loss or a documented intolerance, plus a BMI of 30 or higher, or 27 or higher with a condition such as diabetes, high blood pressure, or sleep apnea, along with a letter of medical necessity from a doctor ^[1].

For people on Wegovy, the steady formulary means continued preferred status, though most plans still require prior authorization, typically involving a BMI threshold, participation in a weight management program, and screening for contraindications such as a personal or family history of medullary thyroid cancer ^[2]. Appeals for denied claims reportedly succeed at rates the source describes as at least 65% for commercial plans and over 80% for Medicare Advantage prior authorization appeals when properly documented, though the same source notes that fewer than 1 in 10 patients who are denied ever file an appeal ^[1][2].

What happens next

The source material notes formulary information is reviewed monthly, meaning further changes for 2026 have not been ruled out ^[1][2]. The two class action lawsuits filed in September 2025 remain pending, and their outcome is not yet known from the available sources.