CVS Caremark

PBM standard commercial template · updated August 30, 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. CVS publishes no member cost-share figure for that return — what a member pays is set by their plan. 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 publishes no member cost-share figure for this; cost depends on your plan's benefit design. 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 these rules come to in dollars — every dose, priced under this coverage:

Foundayo 0.8 mg 2.5 mg 5.5 mg 9 mg 14.5 mg 17.2 mg
Wegovy 0.25 mg 0.5 mg 1 mg 1.7 mg 2.4 mg 7.2 mg
Wegovy® tablets 1.5 mg 4 mg 9 mg 25 mg
Zepbound 2.5 mg 5 mg 7.5 mg 10 mg 12.5 mg 15 mg

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; Wegovy-MASH 12, injection only). Continuation is 12 months in every case.
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. Wegovy 0.25-1 mg: 2 mL/21 days, 6 mL/63 days; 1.7-2.4 mg: 3 mL/21 days, 9 mL/63 days. Wegovy tablets: 30 tablets/25 days, 90 tablets/75 days. The short cycles are deliberate refill headroom: 21 days is used for a 28-day fill and 63 days for an 84-day fill; the tablets run 25 days for a 30-day fill and 75 days for a 90-day fill. So the injections' three-month quantity is an 84-day supply, not a 90-day one.

Primary criteria document: info.caremark.com

Exceptions and appeals

Appeal deadline: 180 days
Deadline detail: 180 days from receipt of denial for Level I, and another 180 from the Level I decision for Level II. External review is a separate and shorter clock: it must be requested within four months of the final internal denial.
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: The Phoenix box is for EXTERNAL review, not for a first appeal: Prescription Claim Appeals MC 109, CVS Caremark, P.O. Box 52084, Phoenix, AZ 85072 · fax 866-443-1172. Send Levels I and II to the address on your own denial letter. Any level above the external review belongs to your plan sponsor, not to CVS, so its deadlines are set by them.

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 to standard commercial template formularies as an additional preferred option 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.