Zepbound is a prescription medication used for weight loss and conditions like obstructive sleep apnea. Many patients rely on insurance to make it affordable. However, recent changes by CVS Caremark have left users wondering: Does CVS Caremark cover Zepbound?
In 2025, CVS Caremark made significant updates to its formulary, impacting Zepbound coverage. This article explains these changes, how they affect you, and steps to navigate them. It also offers tips to secure coverage or find alternatives.
With clear guidance, you can better understand your options and manage costs. Let’s explore the details of Zepbound coverage with CVS Caremark and what you can do next.
Understanding CVS Caremark and Zepbound
CVS Caremark is a major pharmacy benefit manager (PBM) in the U.S. It manages prescription drug coverage for millions of insurance plans. Zepbound, made by Eli Lilly, is a GLP-1 drug for weight loss and related conditions.
Until mid-2025, CVS Caremark included Zepbound on its preferred drug list. However, recent updates have changed its status for many plans. This shift has caused confusion for patients relying on Zepbound.
Understanding how formularies work is key. A formulary is a list of covered medications, updated regularly based on cost and clinical evaluations. Changes can affect whether CVS Caremark covers Zepbound for you.
Related: Does Medicare Cover Zepbound for Sleep Apnea?
Why CVS Caremark Changed Zepbound Coverage
In July 2025, CVS Caremark removed Zepbound from its standard formularies. They now prefer Wegovy, a competing GLP-1 drug by Novo Nordisk. This decision was driven by cost concerns, as GLP-1 drugs like Zepbound have high list prices, often over $1,000 monthly.
The move aims to save 10-15% annually for plan sponsors. However, it has sparked controversy, with patients filing lawsuits claiming CVS ignored medical necessity. They argue Zepbound and Wegovy aren’t interchangeable due to differences in efficacy and side effects.
Not all plans are affected. Some employer or insurer-specific plans still cover Zepbound. Checking your plan’s details is crucial to know your coverage status.
Does CVS Caremark Cover Zepbound in 2025?
For most CVS Caremark plans, Zepbound is no longer a preferred medication as of July 1, 2025. This means automatic denials for new prescriptions or refills unless specific criteria are met. However, coverage varies by plan, so some patients may still have access.
If your plan excludes Zepbound, CVS Caremark requires trying Wegovy first. If Wegovy doesn’t work or causes adverse reactions, you may qualify for Zepbound through an exception. This process involves prior authorizations and appeals.
To confirm coverage, call CVS Caremark using the number on your insurance card. They can clarify if your plan still covers Zepbound or outline your options.
Steps to Navigate Zepbound Coverage Issues
If you’re facing a Zepbound coverage denial, don’t lose hope. There are steps to help you regain access or explore alternatives. Follow these strategies to address the issue.
Check Your Plan Details
Contact CVS Caremark to verify your plan’s formulary. Ask if Zepbound is covered or if Wegovy is the only option. Have your insurance card ready for quick reference.
Some plans may still include Zepbound. If yours doesn’t, ask about the process for exceptions or appeals. This information guides your next steps.
Request a Prior Authorization
If Zepbound is non-preferred, your doctor can submit a prior authorization for Wegovy. If you’ve tried Wegovy and had issues, request a prior authorization for Zepbound. This often requires a denial first to start the appeal process.
Include supporting documents, like a Letter of Medical Necessity. Highlight conditions like sleep apnea or significant weight loss on Zepbound. These strengthen your case for coverage.
File an Appeal
If the prior authorization is denied, file an appeal with CVS Caremark. Your doctor can submit additional evidence, like adverse reactions to Wegovy. Services like Honest Care offer free appeal letter templates to help.
Appeals can take time but may overturn denials. If approved, CVS Caremark may cover Zepbound or even Mounjaro, which has the same active ingredient.
Explore Alternative Options
If Zepbound remains uncovered, ask your doctor about Mounjaro. It contains tirzepatide, like Zepbound, and may be covered for non-diabetic patients. Check with CVS Caremark to confirm eligibility.
You can also look into Eli Lilly’s patient assistance programs or manufacturer coupons. These can reduce costs if insurance doesn’t cover Zepbound.
Table: Zepbound vs. Wegovy Coverage with CVS Caremark
| Aspect | Zepbound | Wegovy |
|---|---|---|
| Active Ingredient | Tirzepatide (GLP-1 and GIP agonist) | Semaglutide (GLP-1 agonist) |
| Coverage Status | Removed from most formularies (July 2025) | Preferred drug as of July 2025 |
| Monthly Cost (List) | ~$1,000+ | ~$1,000+ |
| Prior Authorization | Required, often denied initially | Required but more likely approved |
| Appeal Option | Available with medical necessity proof | Not typically needed |
This table compares Zepbound and Wegovy coverage under CVS Caremark. Use it to understand key differences and plan your approach.
Tips to Manage Zepbound Costs Without Coverage
If CVS Caremark doesn’t cover Zepbound, the high cost can be challenging. List prices often exceed $1,000 monthly without insurance. Here are ways to reduce expenses.
- Use Manufacturer Discounts: Eli Lilly offers savings cards, lowering costs to $25-$650 monthly for eligible patients. Check zepbound.lilly.com for details.
- Compare Pharmacies: Prices vary between pharmacies. Use tools like GoodRx to find the lowest price near you.
- Explore Patient Assistance: Lilly’s programs help uninsured or underinsured patients afford Zepbound. Apply through their official website.
These strategies can make Zepbound more affordable, even without CVS Caremark coverage. Always verify eligibility for discounts or programs.
What to Do if You’re Already on Zepbound
If you’re currently taking Zepbound, your coverage is safe until June 30, 2025. After that, prior authorizations for Zepbound expire, and CVS Caremark may switch you to Wegovy. Your doctor must send a new prescription to avoid disruptions.
Talk to your doctor now to plan ahead. If Zepbound works better for you, request a prior authorization or appeal before the deadline. Acting early prevents gaps in treatment.
If switching to Wegovy isn’t ideal, document any side effects or better results with Zepbound. This evidence supports your appeal for continued coverage.
Staying Informed About Coverage Changes
CVS Caremark updates its formulary quarterly based on cost and clinical factors. Staying updated ensures you’re prepared for changes. Check their website or call regularly for the latest information.
Sign up for alerts from Eli Lilly or CVS Caremark. These notifications share updates on Zepbound coverage or new discount programs. Staying proactive avoids surprises at the pharmacy.
Your doctor or pharmacist can also provide updates. Ask them about formulary changes or alternative medications during visits. This keeps you ahead of coverage shifts.
Summary
The question “Does CVS Caremark cover Zepbound?” has a complex answer due to 2025 formulary changes. As of July 1, 2025, most CVS Caremark plans no longer prefer Zepbound, favoring Wegovy instead. Patients can still seek coverage through prior authorizations or appeals, especially if Wegovy isn’t suitable. Checking your plan, exploring discounts, and acting early are key to managing costs. If coverage is denied, alternatives like Mounjaro or patient assistance programs can help. Stay informed and work with your doctor to ensure access to Zepbound.
FAQ
Does CVS Caremark cover Zepbound after July 1, 2025?
Most CVS Caremark plans no longer cover Zepbound as a preferred drug. Some employer-specific plans may still include it. Call CVS Caremark to confirm your plan’s coverage.
Can I appeal a Zepbound coverage denial?
Yes, you can file an appeal with a Letter of Medical Necessity. Include evidence like adverse reactions to Wegovy or Zepbound’s benefits. Your doctor can help submit this.
What happens to my Zepbound prescription after June 30, 2025?
Prior authorizations for Zepbound expire, and CVS may switch you to Wegovy. Your doctor must submit a new prescription or appeal for Zepbound. Act early to avoid disruptions.
Are there alternatives if CVS Caremark doesn’t cover Zepbound?
Mounjaro, with the same active ingredient, may be covered. Eli Lilly’s savings cards or patient assistance programs can also reduce costs. Check with your pharmacy for options.
How do I know if my plan is affected by the Zepbound coverage change?
Call CVS Caremark using the number on your insurance card. Ask about your plan’s formulary and Zepbound’s status. They can clarify coverage and next steps.
Dr. Hamza is a medical content reviewer with over 12+ years of experience in healthcare research and patient education. He specializes in evidence-based health information, medications, and chronic conditions. His reviews are grounded in trusted medical sources and current clinical guidelines to ensure accuracy, transparency, and reliability. Content reviewed by Dr. Hamza is intended for educational purposes and is not a substitute for professional medical advice.