The Business Behind the Change: PBMs and Formulary Decisions
To understand why Zepbound is no longer on the standard formulary for CVS Caremark plans, it is important to understand the role of a Pharmacy Benefit Manager (PBM). PBMs, like CVS Caremark, act as intermediaries between pharmaceutical manufacturers, insurance companies, and pharmacies. Their primary goal is to manage prescription drug benefits for health plans and employers. A key strategy for controlling costs is through formulary management, which involves negotiating rebates and discounts from drug manufacturers in exchange for preferred placement on the list of covered medications.
In early 2025, CVS Health announced that starting July 1, 2025, its PBM division would no longer cover tirzepatide (Zepbound) on its standard formulary. Instead, it would prioritize coverage of semaglutide (Wegovy). This was a strategic business decision, pitting rival drug manufacturers against each other to secure a better deal for its clients. The move was not based on clinical efficacy or patient outcomes but on financial considerations. For millions of patients with insurance plans managed by CVS Caremark, this translated into losing access to a medication that may have been working well for them.
Options for Patients Affected by the Formulary Change
Patients impacted by the decision are not without options. It is important to remember that while their coverage is affected, the physical drug may still be available. The path forward depends on the patient's individual circumstances and their willingness to explore alternatives.
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Switching to the Preferred Alternative: For many, the most straightforward option is to transition to Wegovy, the new preferred medication. CVS Caremark stated that existing prior authorizations for Zepbound would transition to Wegovy to simplify the process for patients. However, this switch may not be suitable for everyone due to differences in efficacy, side effect profiles, or tolerance.
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Filing a Formulary Exception Appeal: Patients who have clinical reasons to remain on Zepbound, such as an inadequate response or intolerable side effects with Wegovy, can appeal the formulary decision. This requires a formulary exception request from their healthcare provider with supportive clinical documentation. These requests are reviewed on a case-by-case basis.
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Exploring Self-Pay Options via LillyDirect: Eli Lilly, Zepbound's manufacturer, offers a direct-to-consumer service called LillyDirect. This platform allows patients to purchase Zepbound vials directly, bypassing insurance, with discounted pricing options available for self-pay customers. This can be a viable option for those who cannot get insurance coverage, though it requires paying out-of-pocket.
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Finding Zepbound at Other Pharmacies (with unaffected insurance): The formulary change applies to insurance plans using CVS Caremark as their PBM. If a patient changes insurance or has a different PBM, they can likely fill their Zepbound prescription at other major pharmacy chains like Walgreens or Costco, or local independent pharmacies, assuming the medication is in stock.
Zepbound vs. Wegovy: A Clinical and Accessibility Comparison
| Feature | Zepbound (Tirzepatide) | Wegovy (Semaglutide) | Key Implications for Patients |
|---|---|---|---|
| Active Ingredient | Tirzepatide | Semaglutide | Patients may respond differently to each active ingredient. |
| Mechanism of Action | Dual GIP and GLP-1 receptor agonist | GLP-1 receptor agonist | Zepbound's dual action may provide greater weight loss for some individuals compared to Wegovy. |
| FDA-Approved Indications | Chronic weight management, Obstructive Sleep Apnea (OSA) | Chronic weight management, cardiovascular (CV) risk reduction | Approval for OSA is unique to Zepbound, and approval for CV risk reduction is unique to Wegovy (as of July 2025). |
| CVS Formulary Status | Excluded as of July 1, 2025 | Preferred option as of July 1, 2025 | Patients with CVS Caremark-managed plans must transition to Wegovy for covered access, unless they receive a formulary exception. |
| Availability | Widely available, with previous shortages now resolved through increased production. | Widely available, but has faced supply issues in the past. | Supply levels are generally stable for both as of late 2024. |
| Accessibility | Limited by CVS Caremark formulary but available via LillyDirect self-pay. | Preferred coverage on CVS Caremark formulary. | Accessibility and cost are highly dependent on insurance coverage and formulary structure. |
Broader Context of GLP-1 Accessibility and Shortages
Beyond the specific CVS Caremark decision, the market for GLP-1 medications has been characterized by high demand and, at times, significant supply issues. The FDA had previously listed shortages for both tirzepatide (Zepbound and Mounjaro) and semaglutide (Wegovy and Ozempic), causing widespread patient frustration. However, significant investments by manufacturers like Eli Lilly in ramping up production led to the FDA declaring the tirzepatide shortage officially resolved in October 2024. This increased supply enabled PBMs to re-evaluate their formulary strategies and leverage competitive pricing, ultimately leading to decisions like CVS Caremark's. This dynamic highlights the complex interplay between market demand, production capacity, and PBM contracting within the US healthcare system.
Conclusion
The short answer to the question, 'Is Zepbound not available at CVS?' is that it may no longer be covered for many patients whose insurance uses the CVS Caremark PBM, as of July 1, 2025. This decision, driven by financial negotiations rather than clinical reasons, underscores the powerful influence of PBMs on patient access to medications. However, patients have several routes to continue their treatment. Whether by appealing the formulary decision with their physician, exploring alternative self-pay options like LillyDirect, or verifying coverage with a different insurance plan, those needing Zepbound have paths to pursue. Understanding the reasons behind the formulary change and the available patient-focused solutions is critical for navigating this evolving landscape and maintaining consistent care.
Note: For an insightful clinical comparison of Zepbound and Wegovy, a study was published in the New England Journal of Medicine.
## Further Steps for Patients
If your access to Zepbound is impacted, here is a list of actions to take:
* **Contact Your Insurance Provider:** Call the number on your insurance card to confirm if your plan uses CVS Caremark and if Zepbound coverage has ended.
* **Speak with Your Doctor:** Discuss the formulary change and your options, including the possibility of a formulary exception appeal or switching medications.
* **Consider a Formulary Appeal:** Work with your doctor to prepare and submit a medical necessity appeal if a switch to Wegovy is not appropriate for you.
* **Explore LillyDirect:** Investigate the self-pay options for Zepbound directly from the manufacturer if insurance coverage is not an option.
* **Check Other Pharmacies:** If you have a different PBM or plan to pay cash, contact other local or online pharmacies to check stock and pricing.