Express Scripts — the pharmacy benefit manager (PBM) owned by The Cigna Group's Evernorth Health Services division — manages prescription drug coverage for approximately 100 million Americans. Its National Preferred Formulary (NPF) is the industry's most widely used formulary exclusion list and has become the single most important PBM-level gatekeeper for GLP-1 receptor agonist access in the United States.
In 2026, Express Scripts' NPF covers GLP-1s for type 2 diabetes (Ozempic, Mounjaro, Trulicity, Rybelsus) with prior authorization but takes an aggressive position on weight-loss GLP-1s: Wegovy injection, Wegovy tablets, Zepbound pens, and Saxenda are all excluded from the National Preferred Formulary. Zepbound vials are the preferred weight-loss GLP-1 option. This exclusion cascade affects millions of commercially insured Americans whose employers use Express Scripts as their PBM.
This guide maps Express Scripts' GLP-1 formulary positions, details prior authorization requirements, explains the exclusion structure and preferred alternatives, and identifies appeal pathways. It is independent information and not medical advice or reimbursement guidance for a specific patient or plan.
Quick answer
| GLP-1 Drug | Express Scripts NPF Status | PA Required | Tier | Notes |
|---|---|---|---|---|
| Ozempic (semaglutide injection) | Covered — T2D | Yes | Specialty | Preferred GLP-1 for diabetes |
| Mounjaro (tirzepatide injection) | Covered — T2D | Yes | Specialty | PA for diabetes indication |
| Rybelsus (semaglutide tablets) | Covered — T2D | Yes | Specialty | Oral option for diabetes |
| Trulicity (dulaglutide) | Covered — T2D | Yes | Specialty | Preferred GLP-1 for diabetes |
| Wegovy injection (semaglutide 2.4 mg pens) | Excluded | N/A | Nonformulary | Not covered on NPF; liraglutide or Zepbound vials preferred |
| Wegovy tablets (oral semaglutide) | Excluded | N/A | Nonformulary | Not covered on NPF |
| Zepbound pens (tirzepatide) | Excluded | N/A | Nonformulary | Not covered on NPF |
| Zepbound vials (tirzepatide) | Covered — weight loss | Yes | Specialty | Preferred weight-loss GLP-1 on NPF |
| Saxenda (liraglutide 3 mg) | Excluded | N/A | Nonformulary | Not covered; liraglutide generic preferred |
| liraglutide (generic) | Covered — weight loss | Yes | Generic/brand | Preferred alternative to excluded Saxenda/Wegovy |
Key policy dates:
- January 1, 2026: Express Scripts NPF excludes Wegovy injection, Wegovy tablets, Zepbound pens, and Saxenda. Zepbound vials are the preferred weight-loss GLP-1. Continuation of therapy applies through June 30, 2026 for existing utilizers; excluded for all utilizers effective July 1, 2026.
- April 2026: Updated NPF exclusion list (EXCL-NPF-26) published confirming Zepbound vials as the sole preferred weight-loss GLP-1 on the national formulary.
Who this is for
- Patients whose pharmacy benefits are managed by Express Scripts under employer-sponsored, marketplace, or union plans
- Prescribers navigating Express Scripts GLP-1 prior authorization and exclusion appeals
- Benefit verification specialists and hub teams handling Express Scripts claims
- Market access teams at GLP-1 manufacturers tracking Express Scripts formulary decisions
- Employer benefits administrators evaluating Express Scripts GLP-1 coverage options
Source standard
Every fact in this guide is sourced from Express Scripts National Preferred Formulary documents, Express Scripts Medicare PDP formularies, Evernorth publications, and CMS publications dated 2025–2026. Express Scripts formulary rules vary by plan and employer. Always verify current coverage at express-scripts.com or by calling the member services number on your Express Scripts card.
Express Scripts, Evernorth, and Cigna: how they relate
Understanding Express Scripts' GLP-1 decisions requires knowing the corporate structure:
- The Cigna Group (NYSE: CI): Parent company. Owns Cigna HealthCare (insurance), Evernorth Health Services (PBM and services), and Express Scripts (PBM).
- Evernorth Health Services: The services division that houses Express Scripts, eviCore (benefit management), and other health services.
- Express Scripts: The PBM that manages formulary, prior authorization, claims adjudication, and specialty pharmacy distribution for its client plans.
Express Scripts' NPF decisions apply to plans that use the National Preferred Formulary. Self-funded employers may customize their formulary and may choose to cover excluded drugs. Fully insured plans generally follow the NPF unless state law mandates broader coverage.
EncircleRx and the Patient Assurance Program
In addition to formulary exclusions, Express Scripts offers two cost-management programs for GLP-1s:
- EncircleRx: An Express Scripts program with over 9 million enrolled patients that has saved health plans $200 million since 2024. The monthly copay for GLP-1 weight loss medicines is limited to no more than $200 under this program, an estimated savings of up to $3,600 annually.
- Patient Assurance Program: Express Scripts expanded this program to include GLP-1s for weight loss, enabled by agreements with Eli Lilly and Novo Nordisk. Wegovy and Zepbound were added to the program, and diabetes medications Ozempic and Rybelsus were returned to the program.
Diabetes GLP-1 coverage (Ozempic, Mounjaro, Rybelsus, Trulicity)
Express Scripts covers all major GLP-1 receptor agonists for type 2 diabetes on the NPF. These medications are placed in the specialty tier and require prior authorization.
Prior authorization criteria for T2D GLP-1s
Express Scripts' standard PA criteria for diabetes GLP-1s include:
- Type 2 diabetes diagnosis confirmed by ICD-10 code (e.g., E11.x)
- A1C documentation supporting need for GLP-1 therapy
- Prior trial of metformin (first-line therapy) or documented contraindication
- Age ≥ 18 years
- Prescriber attestation of medical necessity
Quantity limits
Express Scripts typically limits GLP-1 dispensing to a 30-day supply at a time for retail pharmacies, with 90-day supply available through Express Scripts Pharmacy (home delivery) for maintenance medications. Quantity limits are noted with "QL" in the formulary.
Step therapy
Some Express Scripts plans impose step therapy requirements — meaning patients must try and fail a preferred GLP-1 before a non-preferred agent is covered. Ozempic and Trulicity are commonly preferred first-line GLP-1s; Mounjaro may require prior trial of a preferred GLP-1 on some plans.
Weight-loss GLP-1 coverage: the NPF exclusion cascade
Express Scripts' 2026 NPF takes the most aggressive PBM exclusion position on weight-loss GLP-1s:
Excluded medications
| Excluded Drug | Exclusion Date | Preferred Alternative |
|---|---|---|
| Wegovy injection (pens) | January 1, 2026 | liraglutide, Zepbound vials |
| Wegovy tablets | January 1, 2026 | liraglutide, Zepbound vials |
| Zepbound pens | January 1, 2026 | Zepbound vials |
| Saxenda | January 1, 2026 | liraglutide, Wegovy injection, Wegovy tablets, Zepbound pens |
Preferred weight-loss GLP-1
Zepbound vials are the sole preferred weight-loss GLP-1 on the 2026 NPF. This is a significant formulary decision that gives Eli Lilly's vial formulation preferred status over Novo Nordisk's Wegovy pen and Lilly's own Zepbound pen formulation.
Continuation-of-therapy transition
For patients already taking an excluded medication at the time of the formulary change:
- New starts: Exclusion effective January 1, 2026
- Existing utilizers: Continuation of therapy applies through June 30, 2026
- All utilizers: Excluded effective July 1, 2026
This means patients taking Wegovy pens or Zepbound pens had a 6-month transition window (January through June 2026) before the exclusion was fully enforced.
Why the exclusions matter
Express Scripts' NPF is used by hundreds of employer plans. When a drug is excluded from the NPF:
- The claim is rejected at the pharmacy
- The member pays 100% of the retail price (typically $900–$1,300/month for GLP-1s)
- Prior authorization cannot override an exclusion — it is a formulary-level decision
- The member must either switch to a preferred alternative, request a formulary exception, or pay cash
Prior authorization for weight-loss GLP-1s (Zepbound vials)
For plans that cover weight-loss GLP-1s through Express Scripts (including those covering Zepbound vials as the preferred agent), PA typically requires:
- BMI ≥ 30 (obesity) or BMI ≥ 27 with at least one weight-related comorbidity
- Documentation of a structured weight management program for at least 6 months
- Prior trial of alternative weight-loss medications (e.g., phentermine, Contrave, Qsymia) or documented contraindication
- Prescriber attestation that lifestyle modifications have been inadequate
- Age ≥ 18
PA submission methods
- Express Scripts online portal: esrx.com/PA — the fastest option for prescribers
- Phone: The prescriber receives a special toll-free number when PA is needed
- Fax: Plan-specific fax number
Express Scripts makes several attempts to contact the prescriber for PA information before notifying the patient that the prescription cannot be filled.
Express Scripts Medicare (Part D) GLP-1 coverage
Express Scripts also administers Medicare Part D plans (Express Scripts Medicare PDP). For Medicare plans:
- T2D GLP-1s (Ozempic, Mounjaro, Rybelsus, Trulicity): Covered under Part D with PA and quantity limits
- Wegovy for cardiovascular risk reduction: Covered with PA under the SELECT trial indication
- Zepbound for OSA: Covered with PA under the SURMOUNT-OSA indication
- Weight-loss GLP-1s: Not covered under standard Part D (statutory exclusion); available through the Medicare GLP-1 Bridge (July 2026 through December 2027)
Express Scripts Medicare PDP formularies note PA requirements with "PA" and quantity limits with "QL" next to each drug listing.
Common denial reasons on Express Scripts
| Denial Reason | What It Means | Fix |
|---|---|---|
| Formulary exclusion | Drug is excluded from the NPF (e.g., Wegovy pens, Zepbound pens) | Request a formulary exception with medical necessity documentation; or switch to preferred alternative (Zepbound vials) |
| Missing PA | PA was not submitted or was incomplete | Prescriber submits PA via esrx.com/PA or fax |
| Step therapy not met | Patient has not tried preferred GLP-1 first | Document prior trial, contraindication, or intolerance |
| Wrong diagnosis code | No T2D or approved-indication ICD-10 code submitted | Ensure correct ICD-10 code accompanies the prescription |
| Quantity limit exceeded | Prescription exceeds 30-day retail or 90-day mail-order limit | Adjust prescribing to match quantity limits |
| Weight-loss benefit not included | The employer plan excludes weight-loss drug coverage | This is a plan-level decision, not a medical necessity denial — explore the CVD or OSA pathway if applicable |
Appeal and formulary exception process
Formulary exception
When a drug is excluded from the NPF, the prescriber can request a formulary exception:
- Prescriber submits a coverage review request at esrx.com/PA
- Include a letter of medical necessity explaining why the excluded drug is required
- Document contraindication, intolerance, or treatment failure with all preferred alternatives
- Express Scripts reviews the exception within 72 hours (standard) or 24 hours (expedited)
Standard appeal
If a PA is denied (not an exclusion):
- Internal appeal: File within 60 days. Express Scripts re-reviews the claim.
- External review: If internal appeal is denied, request independent medical review.
Medicare appeal (5-level process)
For Express Scripts Medicare PDP members:
- Redetermination: File within 60 days
- Reconsideration by IRE
- ALJ hearing
- Medicare Appeals Council review
- Federal district court review
Key takeaways
- Express Scripts' 2026 NPF excludes Wegovy injection, Wegovy tablets, Zepbound pens, and Saxenda — this is the most aggressive PBM exclusion of weight-loss GLP-1s in 2026. Zepbound vials are the sole preferred weight-loss GLP-1.
- Diabetes GLP-1s (Ozempic, Mounjaro, Rybelsus, Trulicity) remain covered with PA on the NPF. Ensure correct T2D diagnosis codes are submitted.
- Existing patients on excluded drugs had until June 30, 2026 to transition — after that date, the exclusion applies to all utilizers.
- Formulary exceptions are possible but require strong medical necessity documentation, including contraindication or treatment failure with all preferred alternatives.
- Self-funded employers may customize their formulary — if your plan is self-funded, ask your HR department whether the employer has overridden the NPF exclusion for weight-loss GLP-1s.
Sources
- Kominski A, et al. "Coverage and Prior Authorization Policies for Semaglutide, Tirzepatide, and Oral Semaglutide." PMC. Published 2026. https://pmc.ncbi.nlm.nih.gov/articles/PMC12397888
- Express Scripts. 2026 National Preferred Formulary. express-scripts.com/pdf/formulary/NPE1702_204612.pdf. Published April 2026.
- Express Scripts. 2026 National Preferred Formulary Exclusion List. express-scripts.com/pdf/formulary/NPF_Preferred_Formulary_Exclusions2026.pdf. EXCL-NPF-26, April 2026.
- Express Scripts. "Frequently Asked Questions: GLP-1 Medications (Diabetes and Weight Management)." militaryrx.express-scripts.com. 2026.
- Medical Mutual. "2026 National Preferred Formulary Changes." medmutual.com. Published August 2025.
- Express Scripts. Express Scripts Medicare (PDP) 2026 Formulary. express-scripts.com. Accessed June 2026.
- Humana. "Does Medicare Cover GLP-1 Weight Loss Drugs?" humana.com. Published May 15, 2026.
- KFF. "What Medicare's Temporary Program Covering GLP-1s for Obesity Means for Beneficiaries." kff.org. March 9, 2026.
- IntuitionLabs. "The ePA Process for GLP-1 Drugs: A Workflow Guide." intuitionlabs.ai. 2026.
- Evernorth. "Express Scripts Expands Patient Assurance Program to Drive Affordability and Access to GLP-1s." evernorth.com. 2026.
