CVS Caremark's Zepbound exclusion carries into 2026 as oral GLP-1s advance
CVS Caremark's removal of Zepbound from most standard formularies is carrying into 2026, so which GLP-1 a plan covers can depend on the pharmacy benefit manager, not the prescription.
CVS Caremark's exclusion of Zepbound (tirzepatide) from most of its standard formularies, in place since July 1, 2025, is continuing into 2026, and it has reshaped which GLP-1 drugs people on those plans can fill [2]. CVS Caremark has confirmed "no new GLP-1 formulary changes" for January 2026 [2].
What CVS Caremark covers now
The pharmacy benefit manager removed Zepbound from its Standard Control, Advanced Control and Value formularies — the lists used by most employers — effective July 1, 2025 [2]. Wegovy (semaglutide) is now the preferred GLP-1 for weight loss, placed on tier 2 or 3 [2]. Mounjaro (tirzepatide) and Ozempic (semaglutide), both for type 2 diabetes, remain covered at tier 2, and Saxenda (liraglutide) is limited at tier 3 [2].
CVS Caremark is a pharmacy benefit manager, not an insurer. It manages drug lists for employers and health plans, and self-funded employers can negotiate to keep Zepbound on their own formularies [2]. GoodRx research cited in a coverage guide updated in April 2026 estimates that more than 100 million Americans lack commercial insurance coverage for Zepbound [2].
Eli Lilly said in August 2025 that the CVS decision had a negative effect on Zepbound prescriptions in July 2025 and was expected to challenge third-quarter sales growth [1].
Lawsuits and the oral GLP-1 race
Two class action lawsuits were filed against CVS Caremark in September 2025: Larkin v. CVS Caremark on Sept. 3 in the Southern District of New York (Case No. 1:25-cv-07307) and Hamburger v. CVS Caremark on Sept. 4 in the District of Columbia [2]. The complaints allege ERISA violations and say CVS prioritized rebate profits, estimating about 200,000 patients were affected. They also note CVS Caremark handles 27% of U.S. pharmacy claims and allege Novo Nordisk pays larger rebates than Eli Lilly [2]. CVS Caremark has called the lawsuits "without merit" [2].
Oral options are advancing. In the first of two phase 3 trials, the highest dose of orforglipron produced average weight loss of 27.3 pounds (12.4%) at 72 weeks, with 59.6% of participants losing at least 10% and 39.6% losing at least 15% [1]. In Novo Nordisk's OASIS 1 trial, a 50 mg daily oral semaglutide dose produced average weight loss of 15.1% over 68 weeks, with nearly 85% of patients losing at least 5% [1]. Novo Nordisk submitted a new drug application for 25 mg oral Wegovy for obesity, with a decision expected by the end of 2025 [1]. Whether that application was approved, and whether CVS Caremark has made coverage decisions about oral GLP-1 drugs, has not been reported.
Why it matters for patients
For people whose prescription benefits run through CVS Caremark, coverage may depend less on what a doctor prescribes than on the PBM's formulary [2].
Zepbound can still be covered through a formulary exception. The listed requirements are trying Wegovy first for 12 to 16 weeks with less than 5% weight loss or a documented intolerance, a BMI of 30 or higher or 27 or higher with a condition such as diabetes, hypertension or sleep apnea, and a letter of medical necessity from a doctor [2].
Appeals are another route. More than 80% of Medicare Advantage prior authorization appeals succeed, and commercial appeals succeed at least 65% of the time when documentation is complete, but fewer than 1 in 10 patients file one, according to the guide [2]. Patients have 180 days to appeal [2].
Some CVS Caremark plans now offer a $200-per-month copay option for GLP-1 weight-loss drugs where no coverage existed before, compared with about $346 a month through TrumpRx.gov and $299 to $449 a month through LillyDirect [2]. Eli Lilly and Novo Nordisk also run direct-to-consumer channels: Lilly says LillyDirect prices are more than 50% below list, and Novo Nordisk says NovoCare prices are up to 60% below list [1].
What happens next
CVS Caremark has said there will be no new GLP-1 formulary changes in January 2026 [2]. The two class action lawsuits were filed in September 2025, and no rulings have been reported [2].
Sources
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