CVS Caremark and Zepbound: The PBM Formulary Tug-of-War

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> Reviewed by FormBlends Medical Team · Last updated May 2026 · 11 sources cited · As of May 2026, confirm directly with your plan

Key Takeaways

• CVS Caremark is the PBM for many large commercial plans including Aetna; its formulary templates ripple across millions of covered lives
• Caremark's GLP-1 formulary preferences shifted in 2024, with some templates moving from Zepbound preference to Wegovy preference
• Plan-specific coverage depends on which Caremark template the employer or insurer adopted
• The December 2024 FDA approval of tirzepatide for moderate-to-severe OSA created a new PA pathway separate from the obesity indication
• LillyDirect's self-pay vial program offers a coverage workaround at approximately $349 to $499 monthly

Direct answer

CVS Caremark's coverage of Zepbound depends on the specific employer or insurer plan contract that uses Caremark as PBM. Caremark operates multiple formulary templates with different GLP-1 preferences. The 2024 PBM formulary churn moved some templates toward Wegovy preference over Zepbound; others maintained Zepbound preference. The December 2024 OSA indication added a separate coverage pathway. Verify with your specific plan formulary.

Table of contents

1. How CVS Caremark fits in the insurance ecosystem
2. The 2024 GLP-1 formulary changes
3. Standard PA criteria for Zepbound
4. The OSA pathway after December 2024
5. How to identify your plan's Caremark template
6. Cost scenarios for covered and uncovered members
7. Switching between GLP-1 medications under Caremark
8. The Aetna relationship
9. Appealing a Caremark denial
10. The contrary view: why PBM formulary preference exists
11. Decision framework
12. FAQ
13. Sources

How CVS Caremark fits in the insurance ecosystem

CVS Caremark is one of the three largest pharmacy benefit managers in the United States, alongside Express Scripts and OptumRx. Caremark is part of CVS Health, which also owns Aetna (acquired in 2018) and the CVS retail pharmacy chain.

Caremark's role is to administer pharmacy benefits for plans that contract with it. The PBM:

• Negotiates drug pricing and rebates with manufacturers
• Creates formulary templates that plans can adopt
• Processes prior authorizations and claims
• Operates specialty pharmacies for high-cost medications
• Provides clinical management programs

Plans using Caremark as PBM include Aetna (the in-house affiliate), many self-funded employer plans, and various commercial insurers that contract with Caremark for pharmacy administration. The PBM does not bear insurance risk; it administers benefits per the contract with each plan.

The 2024 GLP-1 formulary changes

In 2024, CVS Caremark announced significant changes to GLP-1 formulary placement that affected millions of covered members. The changes responded to manufacturer rebate negotiations between Caremark, Novo Nordisk (Wegovy maker), and Eli Lilly (Zepbound maker).

Reports in industry publications including Modern Healthcare, Endpoints News, and Fierce Healthcare described the changes as a shift in preferred status for the obesity indication. Some Caremark formulary templates moved Wegovy to preferred status, with Zepbound moving to non-preferred or excluded status. Other templates maintained Zepbound preference.

The practical effect for members on the affected templates:

• Existing Zepbound users faced potential coverage disruption
• New prescriptions for the non-preferred medication required step therapy through the preferred alternative
• Patients tolerating one medication well faced incentives to switch despite clinical stability
• Pharmacists and physicians had to navigate template-specific rules across multiple patients

The formulary changes remain in flux as PBMs renegotiate with manufacturers annually. As of May 2026, Caremark's standard commercial template preferences continue to evolve.

Standard PA criteria for Zepbound

When Zepbound is covered (rather than excluded or step-therapy-blocked), Caremark PA typically requires:

1. BMI 30 or higher, or BMI 27 with weight-related comorbidities (hypertension, type 2 diabetes, dyslipidemia, OSA)
2. Documentation of participation in a structured weight-management program, typically 3 to 6 months
3. Step therapy through preferred GLP-1 alternative if applicable
4. Attestation of absence of contraindications (personal/family MTC, MEN 2)
5. Documentation of medical necessity

Initial approval is typically 6 months, with continuation requiring clinically meaningful weight loss (usually 5% or more) at reauthorization.

The OSA pathway after December 2024

The FDA's December 2024 approval of tirzepatide for moderate-to-severe obstructive sleep apnea in adults with obesity, based on the SURMOUNT-OSA trials, created a separate coverage pathway. The OSA indication is reimbursable as sleep medicine, not as obesity treatment.

For Caremark plans that exclude or restrict obesity drug coverage, the OSA pathway provides an alternative. Requirements typically include:

• Polysomnography documenting AHI 15 or higher (moderate-to-severe OSA)
• BMI 30 or higher
• Documentation of CPAP intolerance, insufficiency, or contraindication
• Sleep medicine physician co-signature in some plans

The SURMOUNT-OSA trials (Malhotra et al., New England Journal of Medicine 2024) demonstrated substantial AHI reduction with tirzepatide. The trials enrolled patients across CPAP-user and non-CPAP-user populations. Reductions of roughly 25 to 30 events per hour at the 15 mg dose moved many patients from severe to mild OSA classification.

How to identify your plan's Caremark template

Caremark operates multiple formulary templates. The most common include:

• Standard Control Formulary
• Advanced Control Formulary
• Value Formulary
• Custom employer-specific formularies

To identify your specific template:

1. Check the back of your insurance card for plan/group identifiers
2. Log in to caremark.com and search for specific medications
3. Request your Summary Plan Description or Evidence of Coverage from your employer or insurer
4. Call the member services number on your card

The template determines specific PA criteria, preferred alternatives, and step therapy requirements. Two members with Caremark coverage can have very different Zepbound coverage based on which template their plan uses.

Cost scenarios for covered and uncovered members

Scenario	Approximate monthly cost
Covered, tier 3	$50 to $100
Covered, specialty tier	$100 to $200
Covered with Lilly copay card	$25 to $50 (eligibility-dependent)
Uncovered retail cash	Approximately $1,000
LillyDirect 2.5 mg vial	Approximately $349
LillyDirect 5 mg vial	Approximately $499

The Lilly Zepbound Savings Card is available to commercially insured patients with Zepbound coverage. Government insurance members (Medicare, Medicaid, Tricare) are not eligible. Specific terms and discount amounts have shifted multiple times and should be verified at current enrollment.

Switching between GLP-1 medications under Caremark

Caremark formulary changes that move members from Zepbound to Wegovy (or vice versa) require coordinated transitions. The medications are different molecules (tirzepatide for Zepbound, semaglutide for Wegovy) with different titration schedules and tolerability profiles.

Switching considerations:

• Clinical equivalence is approximate, not identical; head-to-head data is limited
• Titration restart may be required when switching molecules
• Tolerability differences are individual; some patients tolerate one better than the other
• The Caremark step-therapy override process allows clinically appropriate exceptions

Members facing forced switches should discuss tolerability and clinical history with their physician. If clinical reasons preclude the switch, the physician can submit a step-therapy override request with supporting documentation.

The Aetna relationship

Aetna uses Caremark as its in-house PBM. Aetna formulary decisions are made by Aetna Pharmacy and Therapeutics committees, but pharmacy benefit administration runs through Caremark. The integration means Aetna coverage rules for Zepbound largely track Caremark's standard templates with Aetna-specific adjustments.

Aetna members and members of other plans using Caremark face similar Zepbound coverage dynamics. The PBM and the insurer are coordinated but technically distinct entities making different layers of the coverage decision.

Appealing a Caremark denial

The appeals process depends on the underlying plan type:

Fully insured commercial plans:

1. Internal first-level appeal to Caremark
2. Peer-to-peer review with Caremark medical director
3. Internal second-level appeal
4. External review through state Independent Review Organization

ERISA self-funded plans:

1. Internal appeals through Caremark per plan procedures
2. Final internal review
3. Federal court review under ERISA

Medicare Part D plans:

1. Coverage determination redetermination
2. IRE reconsideration
3. ALJ hearing
4. Medicare Appeals Council
5. Federal district court

Each pathway has specific deadlines and documentation requirements.

The contrary view: why PBM formulary preference exists

PBM formulary preferences are often criticized as commercially motivated rather than clinically grounded. The criticism has weight. PBMs negotiate rebates with manufacturers and steer members toward medications producing the largest rebate flows. The clinical case for one molecule over another is often thin when both produce similar outcomes.

The steelman: PBM formulary preference is the mechanism by which manufacturers compete on price. Without preference-based contracting, manufacturers face less pressure to discount. The system, despite its frictions, produces some downward pressure on aggregate drug spending.

The countercase: the same dynamics shift patients between molecules based on commercial negotiation rather than clinical fit. Patients on stable therapy face disruption. Physicians spend time navigating formulary changes. The transparency of rebate flows is limited, making it difficult for outside observers to evaluate whether the system actually produces net savings or just shifts costs around.

For individual members, the practical effect is that formulary preference can override clinical preference. Understanding the system helps navigate it.

Decision framework

If Zepbound is preferred on your Caremark template: Pursue standard PA. Document BMI, comorbidities, and any required weight-management program participation.

If Wegovy is preferred and Zepbound is non-preferred: Decide whether to start with Wegovy (the preferred path) or pursue step-therapy override for Zepbound (requires clinical rationale).

If Zepbound is excluded entirely: Explore the OSA pathway if applicable. Consider LillyDirect's self-pay vial option. Appeal denials.

If you have established OSA: Pursue the OSA indication separately from obesity. The pathway is newer and coverage is increasingly available.

If you are stable on Zepbound and facing a forced switch: Discuss clinical implications with your physician. Request step-therapy override if clinically appropriate.

FAQ

Does CVS Caremark cover Zepbound? Plan-dependent. Varies across Caremark formulary templates.

What is CVS Caremark's relationship to insurers? PBM for Aetna and many other commercial and self-funded plans.

Did CVS Caremark drop Zepbound? Some templates moved Wegovy to preferred over Zepbound in 2024; others retained Zepbound preference.

What is the prior authorization for Zepbound at CVS Caremark? BMI 30+ or BMI 27+ with comorbidities, weight-management documentation, step therapy when applicable.

How much does Zepbound cost with CVS Caremark? Covered: $50 to $200. With Lilly copay card: $25 to $50. Uncovered: $1,000 retail or LillyDirect $349 to $499.

What if my plan switched from Zepbound to Wegovy? New prescription required; not automatic.

Can I appeal a Caremark Zepbound denial? Yes; multiple appeal levels available.

Does CVS Caremark cover Zepbound for OSA? Coverage has expanded since December 2024 with sleep-study and CPAP documentation.

Sources

1. FDA, Zepbound (tirzepatide) prescribing information, OSA label expansion, December 2024
2. Malhotra A et al. Tirzepatide for Obstructive Sleep Apnea (SURMOUNT-OSA). New England Journal of Medicine. June 2024
3. Jastreboff AM et al. Tirzepatide Once Weekly for the Treatment of Obesity (SURMOUNT-1). New England Journal of Medicine. 2022
4. CVS Caremark Standard Control Formulary, 2026 plan year
5. CVS Health, GLP-1 formulary changes announcements, 2024 trade press coverage
6. Modern Healthcare reporting on PBM formulary preferences, 2024
7. Eli Lilly, LillyDirect Zepbound self-pay vial program materials, 2025-2026
8. Eli Lilly, Zepbound Savings Card terms and conditions, 2025-2026
9. Aetna Pharmacy Benefit Guide, 2026 plan year
10. ERISA appeals procedures, US Department of Labor
11. Institute for Clinical and Economic Review, Tirzepatide Evidence Report, 2023

Footer disclaimers

Platform Disclaimer. FormBlends provides telehealth services connecting patients with licensed clinicians and 503A compounding pharmacy partners. We do not sell brand Zepbound and have no commercial relationship with Eli Lilly, CVS Caremark, CVS Health, Aetna, or any insurer. Coverage data reflects publicly available information as of May 2026.

Compounded Medication Notice. Compounded tirzepatide prepared by 503A pharmacies is a different product than FDA-approved Zepbound. Compounded medications are not FDA-approved and not interchangeable with brand-name tirzepatide.

Results Disclaimer. Weight loss, AHI improvement, and metabolic outcomes from clinical trials reflect average effects in study populations. Individual response to tirzepatide varies by dose tolerability, adherence, and baseline metabolic status.

Trademark Notice. Zepbound and Mounjaro are registered trademarks of Eli Lilly and Company. Wegovy is a registered trademark of Novo Nordisk A/S. CVS Caremark and Aetna are registered marks of CVS Health Corporation. References here are informational.