On July 1, 2025, a major shift occurred within the pharmacy benefits landscape, affecting countless patients using GLP-1 medications for weight management. CVS Caremark, the pharmacy benefits manager (PBM) for many insurance plans, removed Zepbound (tirzepatide) from its list of preferred drugs, known as the formulary. In its place, the PBM has designated Wegovy (semaglutide) as the primary and preferred formulary option for weight loss. This change, though driven by business decisions, has significant implications for patient care, access, and affordability.
The Reasoning Behind the CVS Formulary Change
CVS Caremark cites the escalating costs and high demand for GLP-1 medications as the primary factors for its formulary update. GLP-1 drugs like Zepbound and Wegovy are among the fastest-growing medication segments, leading to substantial increases in overall pharmacy spending for insurance plans. By negotiating with manufacturers and leveraging its formulary, a PBM like CVS Caremark can secure lower net costs for its clients. The decision to prioritize Wegovy came after a partnership with its manufacturer, Novo Nordisk, with the stated goal of providing wider and more affordable access for members.
This business strategy is not a reflection of a drug's clinical effectiveness but rather a matter of price and negotiation. While this may help manage costs for insurance companies and employers, it can create considerable disruption for patients. Individuals who were responding well to Zepbound now face the difficult decision of switching to a different medication, navigating a complex exception process, or paying the full out-of-pocket cost.
Understanding the Alternatives to Zepbound
For most patients, the primary alternative suggested by CVS Caremark following the formulary change is Wegovy (semaglutide), a once-weekly injectable GLP-1 medication. While both drugs have been shown to be highly effective for weight loss, there are clinical differences that patients should discuss with their healthcare provider. The right choice depends on individual medical history, side effect profile, and potential co-existing conditions.
Clinical Comparison of Zepbound and Wegovy
While Zepbound and Wegovy both belong to the incretin class of drugs and promote weight loss, they target different pathways in the body. Zepbound is a dual GIP/GLP-1 receptor agonist, whereas Wegovy acts solely on GLP-1 receptors.
| Feature | Zepbound (Tirzepatide) | Wegovy (Semaglutide) |
|---|---|---|
| Mechanism of Action | Dual GIP and GLP-1 receptor agonist. | GLP-1 receptor agonist. |
| Reported Weight Loss | In trials, led to greater weight loss on average (approx. 20.2% vs. 13.7% in a head-to-head study). | Significant weight loss in trials (approx. 15%). |
| Key Additional Benefit | Also FDA-approved for treating moderate-to-severe obstructive sleep apnea in adults with obesity. | FDA-approved to reduce the risk of major cardiovascular events (heart attack, stroke) in adults with heart disease. |
| Side Effect Profile | Similar side effects to Wegovy, primarily gastrointestinal. | Similar side effects to Zepbound, primarily gastrointestinal. |
| CVS Formulary Status | Non-preferred for weight management as of July 1, 2025. | Preferred for weight management as of July 1, 2025. |
Additional Alternative Medications
Beyond Wegovy, other older-generation or oral weight-management medications may be considered, though they often produce less dramatic weight loss results. These options include:
- Saxenda (liraglutide): An injectable GLP-1 agonist that is administered daily.
- Qsymia (phentermine/topiramate ER): A combination oral medication that suppresses appetite.
- Contrave (naltrexone/bupropion): An oral medication that targets the parts of the brain controlling appetite and cravings.
- Orlistat (Xenical/Alli): An oral medication that reduces the amount of fat absorbed by the body.
What to Do if You Were on Zepbound
For patients impacted by the change, several steps need to be taken to ensure continuity of care:
- Contact your healthcare provider. Your provider can discuss the best course of action, which may include transitioning to Wegovy or seeking a formulary exception for Zepbound.
- Navigate the prior authorization process for Wegovy. If switching, any existing prior authorization for Zepbound will be transitioned to Wegovy, though a new request will be needed upon expiration.
- Explore the formulary exception process for Zepbound. If Wegovy is not an option (e.g., due to previous failure or side effects), your provider can file a formulary exception request. This process requires documentation demonstrating medical necessity and may involve proving you have tried and failed Wegovy.
- Consider manufacturer savings programs or out-of-pocket payment. If an exception is denied or coverage remains an issue, manufacturer programs through services like LillyDirect may provide options, though they may still be costly.
Conclusion
CVS Caremark's decision to favor Wegovy over Zepbound on its standard formulary is a strategic move driven by cost management, not clinical efficacy. While it may secure lower costs for some plans, it creates a new set of challenges for patients who relied on Zepbound. The formulary shift underscores the importance of staying informed about your insurance coverage and maintaining open communication with your healthcare provider. For those affected, transitioning to Wegovy or navigating the exception process is the next step to ensure continued access to effective weight management treatment.
The Shifting Landscape of PBMs and Drug Coverage
Decisions by PBMs like CVS Caremark often spark debate about the balance between cost-containment and patient choice. The high list price of GLP-1 medications has put immense pressure on insurance providers, forcing difficult formulary decisions. The removal of Zepbound is a prime example of how these contracts between PBMs and pharmaceutical companies directly impact what is covered, and at what cost, for patients. As the market for weight-loss medications continues to evolve, patients can expect more frequent changes to formularies, highlighting the need for active engagement with their healthcare providers and insurance plans to secure the most appropriate and affordable care.
Visit the Mass.gov page for an official announcement on the CVS formulary change
