CVS Caremark, the pharmacy benefit manager serving approximately 88 million plan members, has been the most aggressive PBM in reshaping GLP-1 formulary policy. In July 2025, Caremark removed tirzepatide (Zepbound) from its standard commercial formularies and designated semaglutide (Wegovy) as the preferred GLP-1 for obesity treatment. That decision forced hundreds of thousands of patients to switch molecules or pursue formulary exceptions — and triggered a 16-fold surge in GLP-1 switching rates, according to Truveta research presented at AMCP 2026.
Now, Caremark is reversing course. On May 28, 2026, CVS Health announced that Zepbound will return to commercial formularies as an additional preferred option effective October 1, 2026. The PBM is also removing the new-to-market block on Foundayo (orforglipron), the first oral GLP-1 therapy, effective June 1, 2026. These changes reflect negotiated pricing progress with manufacturers and plan-sponsor demand for broader access.
This guide is for market access teams, benefit verification specialists, formulary strategists, and hub-services operators who need to understand CVS Caremark's current GLP-1 formulary architecture, prior authorization criteria, and what changes mean for patient access. It is not medical advice or reimbursement guidance for a specific patient or plan.
Quick answer
| GLP-1 Drug | CVS Caremark Status (2026) | Formulary Tier | PA Required | Key Change |
|---|---|---|---|---|
| Wegovy (semaglutide) | Preferred GLP-1 for obesity | Specialty / Tier 4–5 | Yes | Remained on formulary throughout 2025–2026; preferred status |
| Zepbound (tirzepatide) | Returning as additional preferred option Oct 1, 2026 | Specialty / Tier 4–5 | Yes | Removed July 2025; reinstated Oct 2026 |
| Foundayo (orforglipron oral) | New-to-market block removed June 1, 2026 | Plan-dependent | Yes | Block lifted where plans approve coverage |
| Ozempic (semaglutide) | Covered for T2D only | Preferred brand / Tier 2–3 | Yes | Not covered for weight loss |
| Mounjaro (tirzepatide) | Covered for T2D only | Preferred brand / Tier 2–3 | Yes | Not covered for weight loss |
| Saxenda (liraglutide) | Covered with PA | Non-preferred | Yes | Older GLP-1; non-preferred status |
| Rybelsus (oral semaglutide) | Covered for T2D | Plan-dependent | Yes | T2D only |
| Trulicity (dulaglutide) | Covered for T2D | Plan-dependent | Yes | T2D only |
Who this is for
- Market access and payer strategy teams at GLP-1 manufacturers
- Benefit verification and prior authorization specialists at specialty pharmacies
- Formulary and PBM consultants evaluating Caremark template formulary design
- Employer benefit managers whose plans use CVS Caremark
- Prescribers navigating Caremark PA requirements
Source standard
Every fact in this guide is sourced from CVS Health announcements, Caremark formulary documents, state regulatory filings, and peer-reviewed research dated 2025–2026. Formulary status varies by plan sponsor election. Always verify current formulary and PA criteria on the specific plan's member portal or Caremark's Medication Lookup tool.
Timeline of CVS Caremark GLP-1 formulary changes
July 2025: Zepbound removed, Wegovy designated preferred
In May 2025, CVS Caremark announced that Zepbound (tirzepatide injection) would be removed from its standard commercial formularies effective July 1, 2025. Wegovy became the preferred GLP-1 for obesity treatment. Key details:
- All existing Zepbound prior authorizations were transitioned to Wegovy, including those approved for obstructive sleep apnea
- Members were required to try and fail Wegovy before accessing tirzepatide through a formulary exception
- Caremark reached out to providers on behalf of each affected member to request new Wegovy prescriptions
- The change applied only to the obesity indication; tirzepatide (Mounjaro) remained available for type 2 diabetes
According to Truveta research presented at AMCP 2026, the impact was immediate and dramatic:
- Switching from anti-obesity tirzepatide surged from 0.6% to 9.7% — a 16-fold increase
- 8 in 10 patients who switched moved to Wegovy (semaglutide)
- Switching rates remained elevated at approximately 1.6% through September before returning to baseline in October 2025
May 28, 2026: Zepbound return and Foundayo unblock announced
CVS Health announced two major formulary changes effective for the 2026 plan year:
Zepbound returns October 1, 2026: Added back to most common commercial formularies as an additional preferred option. Plan sponsors retain discretion to customize coverage.
Foundayo new-to-market block removed June 1, 2026: The new-to-market exclusion on orforglipron, the first FDA-approved oral GLP-1 for chronic weight management, is lifted for plans that have approved coverage.
CVS Caremark attributed the changes to successful manufacturer negotiations that achieved better-than-expected net pricing. Ed DeVaney, President of CVS Caremark, stated: "We're creating access and options that would not have existed without our leadership in the market."
Cost trends: 15% per-prescription decrease expected
CVS Caremark's 2026 GLP-1 Insights Report projects a roughly 15% decrease in per-prescription net cost in 2026 compared to 2025 for commercial template formulary clients with standard utilization management. Key cost drivers:
- Proactive manufacturer negotiations across injectable and oral GLP-1s
- Better-than-expected net pricing secured ahead of oral Wegovy's anticipated launch
- Formulary optimization guiding members to cost-effective therapies
- Template formulary clients experienced year-over-year double-digit savings in the weight management category
Prior authorization criteria on CVS Caremark plans
Weight management GLP-1s (Wegovy, Zepbound, Saxenda)
PA requirements vary by plan sponsor but typically include:
- BMI threshold: BMI ≥30 (obesity), or BMI ≥27 (overweight) with at least one weight-related comorbidity (hypertension, type 2 diabetes, dyslipidemia, sleep apnea)
- Lifestyle program: Participation in a comprehensive weight management program for at least 6 months prior to therapy, including reduced-calorie diet and increased physical activity
- Documentation: Current height, weight, and calculated BMI must be submitted with the PA request
- Quantity limits: Dispensing limit of 30 days for GLP-1 medications used for weight loss
- Step therapy: Some plans require trial of older anti-obesity medications (Contrave, Qsymia, orlistat) before GLP-1 approval
Diabetes GLP-1s (Ozempic, Mounjaro, Rybelsus, Trulicity)
- Diagnosis required: Documented type 2 diabetes mellitus (ICD-10 E11.x)
- Prior therapy: Documented trial of metformin or other first-line oral agents
- PA duration: Typically 12 months, with reauthorization requiring continued medical necessity
Formulary exceptions for Zepbound (pre-October 2026)
Before October 1, 2026, members seeking Zepbound coverage on Caremark plans must pursue a formulary exception with clinical justification, which may include:
- Documented failure, intolerance, or contraindication to Wegovy (semaglutide)
- Documented superior response to tirzepatide in a prior treatment episode
- Clinical rationale from the prescriber explaining why semaglutide is not appropriate
GEHA as a case study
GEHA (Government Employees Health Association), a federal employee health plan that uses CVS Caremark as its PBM, illustrates how formulary tiering affects member costs in 2026:
- Liraglutide (generic): Generic medication, PA required
- Wegovy: Non-preferred medication, PA required — out-of-pocket costs higher than preferred options
- Saxenda: Non-preferred medication, PA required
- Zepbound: Non-formulary medication, formulary exception required
- For GEHA Elevate plan members: Wegovy and Saxenda are listed as preferred medications, while Zepbound remains non-formulary
What access teams should monitor
Short-term (June–October 2026)
- Zepbound transition logistics: Plan sponsors must elect to add Zepbound back to their formularies. Access teams should confirm each employer client's formulary election before October 1.
- Foundayo uptake: The oral GLP-1 is newly available without the new-to-market block, but plan-level coverage adoption will be uneven. Verify plan-specific formulary status before submitting PA.
- Oral Wegovy launch: Caremark has signaled it secured favorable net pricing ahead of oral Wegovy's anticipated launch. Monitor formulary placement and PA criteria for the oral semaglutide product.
Medium-term (2027)
- BALANCE Model: CMS's BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model, launching in 2026 for Medicaid, may expand to Medicare and influence PBM formulary decisions. CVS Caremark's parent company, CVS Health, also operates Aetna Medicare Advantage plans.
- GLP-1 net cost trajectory: Caremark projects continued per-prescription cost reduction. If net costs decline further, expect broader formulary access and potentially reduced step therapy requirements.
- Competitive PBM dynamics: Express Scripts and OptumRx are expanding GLP-1 coverage in parallel. Caremark's formulary strategy will be shaped by competitive pressure to maintain employer clients.
Key takeaways
- CVS Caremark reversed its Zepbound exclusion and will restore tirzepatide to commercial formularies on October 1, 2026, as an additional preferred option alongside Wegovy.
- The new-to-market block on oral GLP-1 Foundayo was removed June 1, 2026, giving plan sponsors the option to cover the first oral incretin therapy.
- Wegovy remains the preferred GLP-1 for obesity on Caremark template formularies; members wanting Zepbound before October 2026 must pursue a formulary exception.
- Per-prescription net cost is projected to decline approximately 15% in 2026 compared to 2025, driven by manufacturer negotiations and formulary optimization.
- PA criteria typically require BMI documentation, a 6-month lifestyle program, and prior therapy documentation. Plan sponsors retain discretion to customize requirements.
This is independent information and not medical advice, reimbursement guidance, or a recommendation for any specific payer plan.
Sources
- CVS Health. "CVS Caremark delivers affordability and access to GLP-1 weight management medications with expanded coverage options." Press release, May 28, 2026. https://www.cvshealth.com/news/company-news/cvs-caremark-delivers-affordability-and-access-to-glp-1-weight-management-medications-with-expanded-coverage-options.html
- CVS Caremark. "2026 GLP-1 Outlook: Insights Report." https://business.caremark.com/content/dam/enterprise/business-caremark/insights/pdfs/2026/2026_glp1_insights_report.pdf
- Commonwealth of Massachusetts. "CVS Caremark decides to remove Zepbound from CVS Caremark formulary." https://www.mass.gov/news/cvs-caremark-decides-to-remove-zepbound-from-cvs-caremark-formulary
- Truveta. "Impact of CVS GLP-1 formulary change on prescribing." AMCP 2026 poster. https://www.truveta.com/blog/research/amcp-2026-impact-cvs-glp-1-formulary-change
- GEHA. "Pharmacy Coverage for Weight Loss GLP-1 Medications." 2026. https://www.geha.com/~/media93/Project/GEHA/GEHA/documents-files/prescriptions/geha-pharmacy-coverage-for-weight-loss-glp-1-medications.pdf
- Pharmaceutical Commerce. "CVS Caremark Expands GLP-1 Formulary Coverage." May 29, 2026. https://www.pharmaceuticalcommerce.com/view/cvs-caremark-expands-glp-1-formulary-coverage
- CVS Caremark. "Performance Drug List – Basic Control." January 2026. https://www.oefi.org/wp-content/uploads/2026/01/CVSCaremark-Jan2026-formulary.pdf
- Indiana University. "CVS Caremark changes coverage for weight loss drug." June 5, 2025. https://today.iu.edu/live/news/45894-cvs-caremark-changes-coverage-for-weight-loss-drug
- FDA. "FDA Approves New Indications for Wegovy (semaglutide) Injection." https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers
- CMS. "GLP-1 Bridge Demonstration and BALANCE Model." 2026. https://www.cms.gov/newsroom/fact-sheets/cms-announces-glp-1-bridge-and-balance-model
