Zepbound, a popular weight loss drug, has been a game-changer for many. But is CVS Caremark dropping Zepbound from its coverage?
This article explains the recent decision, its impact, and what patients can do in simple terms.
What is Zepbound?
Zepbound, made by Eli Lilly, is an injectable medication with tirzepatide as its active ingredient. It’s FDA-approved for weight management in adults with obesity or weight-related conditions. It works by mimicking GLP-1 and GIP hormones to reduce appetite and improve metabolism.
The drug is taken weekly and has shown strong results in clinical trials. Many patients prefer it for its effectiveness and fewer side effects compared to alternatives. It’s also approved for treating obstructive sleep apnea in obese patients.
CVS Caremark’s Decision Explained
On May 1, 2025, CVS Caremark announced it will remove Zepbound from its standard formulary starting July 1, 2025. Instead, it will prioritize Wegovy, a competing GLP-1 drug by Novo Nordisk, for weight loss coverage. This move affects millions of patients with CVS Caremark-managed insurance plans.
The decision stems from negotiations between pharmacy benefit managers (PBMs) and drugmakers.
CVS Caremark likely secured better pricing or rebates from Novo Nordisk. This prioritizes cost savings over clinical differences between the drugs.
Why Is This Happening?
PBMs like CVS Caremark manage prescription drug coverage for insurance plans. They negotiate with drugmakers to lower costs, often favoring one drug over another for formulary placement. In this case, Wegovy was chosen over Zepbound for financial reasons.
Clinical trials, like SURMOUNT-5, show Zepbound leads to greater weight loss (20.2%) than Wegovy (13.7%) over 72 weeks.
Despite this, CVS Caremark’s decision reflects a focus on cost rather than efficacy. This has sparked frustration among patients and providers.
How Will This Affect Patients?
For patients using Zepbound, the change could mean higher out-of-pocket costs after July 1, 2025. Some may lose coverage entirely, depending on their plan. CVS Caremark will transition existing Zepbound prior authorizations to Wegovy automatically.
Not all patients respond the same to Wegovy. Some may experience different side effects or less weight loss.
This switch could disrupt treatment plans, especially for those who found Zepbound more effective or tolerable.
Who Is Impacted?
The change affects patients whose insurance uses CVS Caremark’s standard formulary. About 90 million Americans are under CVS Caremark’s management, though not all plans will drop Zepbound. Self-insured plans or custom formularies may still cover it.
Patients with employer-based insurance should check with their benefits office. Those with conditions like sleep apnea, where Zepbound has unique approval, may have options to appeal. Contacting CVS Caremark directly can clarify your plan’s status.
What Can Patients Do?
If you’re affected by CVS Caremark dropping Zepbound, there are steps to take. Acting before July 1, 2025, can help maintain access or ease the transition. Here are some options:
- Check Your Plan: Call CVS Caremark to confirm if your formulary is affected.
- Request a 90-Day Supply: Ask your doctor for a 90-day prescription before July 1 to extend coverage.
- File an Appeal: Submit a formulary exception or continuation of care request with your doctor.
- Explore Self-Pay: Use LillyDirect for Zepbound at $349–$499 per month, if affordable.
The Role of Pharmacy Benefit Managers
PBMs like CVS Caremark control which drugs are covered and at what cost. They negotiate rebates with drugmakers, influencing formulary decisions. This often prioritizes financial deals over patient outcomes.
Critics argue this system limits patient choice. For example, Zepbound’s removal isn’t based on clinical inferiority but on behind-the-scenes contracts. This highlights the power PBMs have over healthcare access.
Comparing Zepbound and Wegovy
Zepbound and Wegovy are both GLP-1-based drugs, but they differ in key ways. Zepbound targets both GLP-1 and GIP receptors, leading to greater weight loss in trials. Wegovy, a single GLP-1 agonist, is FDA-approved for cardiovascular risk reduction, unlike Zepbound.
Patients report better tolerability with Zepbound, with less nausea and vomiting. Switching to Wegovy may require dose adjustments and could lead to new side effects. Discussing options with your doctor is crucial.
Table: Zepbound vs. Wegovy Key Differences
| Feature | Zepbound | Wegovy |
|---|---|---|
| Active Ingredient | Tirzepatide (GLP-1 and GIP agonist) | Semaglutide (GLP-1 agonist) |
| Average Weight Loss | 20.2% (SURMOUNT-5 trial) | 13.7% (SURMOUNT-5 trial) |
| FDA Approvals | Weight loss, sleep apnea | Weight loss, cardiovascular risk |
| Common Side Effects | Nausea, diarrhea, better tolerability | Nausea, vomiting, less tolerable for some |
Lilly’s Response to the Change
Eli Lilly has taken steps to maintain patient access to Zepbound. They’ve launched LillyDirect, a direct-to-consumer pharmacy with Zepbound priced at $349–$499 per month. This bypasses PBM restrictions but is costly for many.
Lilly also offers copay assistance and patient support programs. They’re working to expand formulary coverage with other PBMs like Express Scripts and OptumRx. These efforts aim to keep Zepbound accessible despite CVS Caremark’s decision.
Patient and Provider Pushback
Patients and healthcare providers are frustrated with CVS Caremark’s move. A petition on Change.org, with nearly 10,000 signatures, urges CVS to reverse the decision. It cites Zepbound’s superior efficacy and tolerability.
Providers argue the switch undermines personalized care. Forcing patients to change medications can disrupt progress and increase administrative burdens. Many are filing appeals to keep patients on Zepbound.
Legal and Advocacy Efforts
Some patients are exploring legal options, especially in states with laws requiring coverage of all FDA-approved weight loss drugs.
For example, Illinois law mandates coverage, prompting complaints to state authorities. Advocacy groups like the Obesity Action Coalition offer resources to challenge coverage denials.
Writing to lawmakers or employers can also help. Raising awareness about PBM practices may push for policy changes. Patients are encouraged to share their stories to highlight the impact.
Self-Pay and Alternative Options
For those losing coverage, self-pay options like LillyDirect are available. Prices range from $349 for a 2.5 mg dose to $499 for 10 mg. Higher doses like 12.5 mg or 15 mg may not be available through LillyDirect yet.
Compounded tirzepatide, though not FDA-approved, is offered by some pharmacies during shortages. Patients should consult their doctor before considering this. Switching to Wegovy or other covered drugs like Saxenda is another option.
The Bigger Picture
CVS Caremark’s decision reflects broader issues in the U.S. healthcare system. PBMs hold significant power over drug access, often prioritizing profits over patient needs. This case highlights the tension between cost management and clinical care.
As demand for GLP-1 drugs grows, similar decisions may affect other medications. Patients and providers must advocate for transparency and choice in formulary decisions. This ensures treatments align with medical needs.
What’s Next for Zepbound Users?
Patients should act quickly to secure Zepbound before July 1, 2025. Checking your plan, requesting prior authorizations, or exploring self-pay options can help. Staying in touch with your doctor is key to navigating changes.
Eli Lilly is likely to continue pushing for broader coverage. Meanwhile, ongoing research may further clarify Zepbound’s benefits, potentially influencing future PBM decisions. Advocacy and awareness remain critical for patients.
Summary
Is CVS Caremark dropping Zepbound? Yes, starting July 1, 2025, Zepbound will be removed from their standard formulary, with Wegovy taking its place. This decision, driven by cost negotiations, may disrupt treatment for many patients.
Options like appeals, self-pay through LillyDirect, or switching to Wegovy can help. Staying proactive and working with your doctor is essential to maintain access to the best treatment for you.
FAQ
Is CVS Caremark dropping Zepbound from all plans?
Not all plans are affected; only those using CVS Caremark’s standard formulary. Custom formularies or self-insured plans may still cover Zepbound. Contact CVS Caremark to confirm your plan’s status.
Why is CVS Caremark prioritizing Wegovy over Zepbound?
CVS Caremark likely secured better pricing or rebates from Novo Nordisk, Wegovy’s maker. This financial decision outweighs clinical evidence showing Zepbound’s superior weight loss. Patients may face higher costs or need to switch.
Can I stay on Zepbound after July 1, 2025?
You may request a formulary exception or continuation of care with your doctor. Self-pay options like LillyDirect are available at $349–$499 per month. Check with your insurance for non-formulary coverage.
What if Wegovy doesn’t work for me?
If Wegovy causes side effects or is less effective, your doctor can file an appeal citing medical necessity. Include clinical data or your treatment history. Discuss alternative covered drugs like Saxenda if needed.
How can I advocate for Zepbound coverage?
Contact your employer’s benefits office or sign petitions like the one on Change.org. Write to lawmakers, especially in states with coverage laws. Sharing your story can push for policy changes.
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