CVS Caremark
PBM standard commercial template · updated August 8, 2026
Coverage right now
- Foundayo™ (orforglipron) Covered
- Saxenda® (liraglutide) Covered
- Wegovy® (semaglutide injection) Preferred
- Wegovy® tablets (oral semaglutide) Covered
- Zepbound® (tirzepatide) Excluded
Largest US PBM. Removed Zepbound from standard commercial template formularies July 1, 2025 (Wegovy preferred); returns Zepbound as an additional preferred option October 1, 2026 at ~$25/month for eligible commercial members. Template criteria — plan sponsors customize, and many employer plans exclude weight-loss drugs entirely.
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Zepbound® (tirzepatide) | Excluded from Jul 1, 2025 to Sep 30, 2026 | Excluded from standard commercial template formularies (existing PAs were transitioned to Wegovy without a new PA). source | high |
| Zepbound® (tirzepatide) | Preferred from Oct 1, 2026 | Returns as an additional preferred option; CVS cites ~$25/month for eligible commercial members under negotiated pricing. source | high |
| Wegovy® (semaglutide injection) | Preferred from Jul 1, 2025 | Preferred GLP-1 for obesity on template formularies since July 1, 2025; reaffirmed May 28, 2026. source | high |
| Wegovy® tablets (oral semaglutide) | Covered from Jan 5, 2026 | Covered with PA under the Wegovy criteria document (4774-C family). source | medium |
| Foundayo™ (orforglipron) | Covered from Jun 1, 2026 | New-to-market block removed June 1, 2026 where the plan covers weight-loss drugs; not announced as preferred. source | high |
| Saxenda® (liraglutide) | Covered from Jul 1, 2025 | Preferred alongside Wegovy as of July 2025; 2026 template status not directly re-verified (generic liraglutide now on market). source | medium |
What preferred, covered and exception only mean
- Preferred
- On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
- Covered
- On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
- Non preferred
- On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
- Exception only
- Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
- Excluded
- Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
- Varies
- The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
- Unknown
- Not yet verified against a primary document. Recorded as absent rather than guessed.
- N/A
- Not applicable to this payer.
Prior authorization criteria
high- PA required
- Yes, where the plan includes a weight-loss benefit. Many employers exclude the benefit entirely — a benefit exclusion is not appealable as a PA denial.
- Initial BMI
- Baseline BMI >= 30, OR baseline BMI >= 27 with at least one weight-related comorbid condition. Pediatric (Wegovy inj, 12-17): BMI >= 95th percentile for age/sex.
- Comorbidities
- e.g., hypertension, type 2 diabetes mellitus, dyslipidemia (explicitly non-exhaustive list).
- Lifestyle requirement
- Participation in a comprehensive weight management program (behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up) for at least 6 months.
- Initial authorization
- Zepbound 8 · Wegovy injection 7 · Wegovy tablets 6 (Zepbound-OSA 6; Wegovy-CV 12)
- Reauthorization
- Lost at least 5% of baseline body weight OR maintained the initial 5% loss, assessed after >= 3 months at a stable maintenance dose. Reauthorization lasts 12 months.
- Step therapy
- None documented inside the weight-loss GLP-1 criteria (the 2025-2026 Wegovy preference operated as a formulary exclusion, not a step).
- Quantity limits
- Zepbound: 2 mL (4 pens or 4 single-dose vials) per 21 days; 6 mL per 63 days for 90-day supply. Wegovy 0.25-1 mg: 2 mL/21 days; 1.7-2.4 mg: 3 mL/21 days. Wegovy tablets: 30 tablets/25 days. Note the unusual 21-day cycle.
Primary criteria document:info.caremark.com
Exceptions and appeals
- Appeal deadline
- 180 days
- Deadline detail
- 180 days from receipt of denial, Levels I-II.
- Exception route
- Prescriber-initiated ePA at caremark.com/epa (CoverMyMeds/Surescripts). Non-Medicare PA phone 1-800-294-5979, fax 1-888-836-0730. Exclusion exceptions accepted only after the exclusion effective date.
- Turnaround
- ~72 hours from receipt for non-urgent PA (Caremark client document); ERISA maxima (15 days pre-service) apply.
- Where
- CVS Caremark Appeals, P.O. Box 52084, Phoenix, AZ 85072 · fax 866-443-1172
Source:dhr.delaware.gov
Dated changes
- May 1, 2025 Announced Wegovy as preferred GLP-1 for obesity source
- Jul 1, 2025 Zepbound removed from standard commercial template formularies; switching among 700,907 tracked patients spiked 17x (0.6% to 10.2%/month, June-July) source
- Jun 1, 2026 Foundayo new-to-market block removed source
- Oct 1, 2026 Zepbound returns as additional preferred option (~$25/month for eligible commercial members) source
Criteria cited are the P08-2025 template versions (Standard Control Formulary family). If your plan is Caremark-administered but employer-customized, your criteria may differ — ask for the plan-specific criteria document in writing.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.