in 4 days Aetna (CVS Health) — Zepbound back as additional preferred on templates See the changelog
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Express Scripts (Evernorth / Cigna)

PBM standard commercial template (National Preferred Formulary) · updated August 26, 2026

Coverage right now

Kept both Wegovy and Zepbound single-dose pens preferred through the 2025 upheaval. 2026 NPF: Zepbound pens, Wegovy (pens, HD, tablets), and Foundayo all preferred — but Zepbound KwikPens and vials are excluded (device-level steering), and Saxenda is excluded in favour of generic liraglutide. PA criteria run through the Cigna National Formulary policy cnf_684.

Drug status

DrugStatusDetailConfidence
Zepbound® (tirzepatide)Preferred
from Jan 1, 2026
Single-dose pens preferred on the 2026 National Preferred Formulary. KwikPens and vials EXCLUDED (alternatives: Zepbound pens, Wegovy, Foundayo, liraglutide). sourcehigh
Wegovy® (semaglutide injection)Preferred
from Jan 1, 2026
Pens and HD preferred. sourcehigh
Wegovy® tablets (oral semaglutide)Preferred
from Jan 5, 2026
Wegovy tablets preferred on the 2026 NPF. sourcehigh
Foundayo™ (orforglipron)Preferred
from Jul 1, 2026
Listed preferred in the 07/01/2026 NPF — one of the fastest adds of the new oral. sourcehigh
Saxenda® (liraglutide)Excluded
from Jan 1, 2026
Excluded from the 2026 National Preferred Formulary. Listed under 'Excluded Medications/Products at a Glance' with the brand-exclusion-with-generic-equivalent marker, meaning generic liraglutide is the covered agent. Not on the covered PDL. A benefit exclusion is appealed differently from a PA denial. sourcehigh

What these rules come to in dollars — every dose, priced under this coverage:

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 covers weight loss (EncircleRx adds employer-level eligibility management; participating plans cap member GLP-1 cost at <= $200/month).
Initial BMI
Baseline BMI >= 30, OR baseline BMI >= 27 with >= 1 weight-related comorbidity. Pediatric (12-17, Wegovy/liraglutide): BMI >= 95th percentile. Age >= 18 for Zepbound/Foundayo.
Comorbidities
Hypertension, T2D, dyslipidemia, OSA, cardiovascular disease, knee osteoarthritis, asthma, COPD, MASLD/NAFLD, PCOS, or coronary artery disease — the broadest published list among major PBMs.
Lifestyle requirement
Trial of behavioral modification and dietary restriction for at least 3 months, AND concomitant use with behavior modification and reduced-calorie diet.
Initial authorization
8 (Wegovy, Zepbound, Foundayo) · 4 (liraglutide/Saxenda)
Reauthorization
Lost >= 5% of baseline body weight (>= 4% liraglutide; pediatric: BMI reduction >= 1%). Baseline = before any GLP-1. Reauthorization lasts 1 year.
Step therapy
None in the PA policy; steering happens at device level via formulary exclusions (KwikPen/vial excluded).
Quantity limits
Zepbound: 2 mL (4 pens or vials) per 28 days retail; 6 mL (12) per 84 days home delivery — no overrides (policy cnf_840). Separately, and across the whole class: only ONE claim for ONE GLP-1 or GLP-1/GIP agonist is approved every 21 days, on fills of a 28-day supply or more, with no overrides recommended for any of Saxenda, Foundayo, Wegovy, Wegovy HD, Wegovy tablets or Zepbound (policy cnf_894, reviewed 01/07/2026, revised 04/08/2026). That rule looks across retail fills, so switching product mid-month is what it stops.

Primary criteria document: static.cigna.com· static.cigna.com

Exceptions and appeals

Appeal deadline
180 days
Deadline detail
180 days from receipt of the adverse determination (Level 2: 90 days).
Exception route
Prescriber ePA via esrx.com/PA, ExpressPAth, CoverMyMeds, or Surescripts. Clinical appeals: Express Scripts, Attn: Clinical Appeals Department, P.O. Box 66588, St. Louis, MO 63166-6588 · fax 877-852-4070 · urgent 800-753-2851.
Turnaround
ESI states nearly all coverage reviews complete within two days of complete information; ePA can return in minutes. Regulatory frame: 72 hours urgent, 15 days pre-service.
Where
Express Scripts, Attn: Clinical Appeals Department, P.O. Box 66588, St. Louis, MO 63166-6588 · fax 877-852-4070

Source: hr.jhu.edu· express-scripts.com

Dated changes

  • Jan 1, 2026 2026 NPF year began — 48 new exclusions, GLP-1 anti-obesity class core retained source
  • Jan 1, 2026 Saxenda excluded from the National Preferred Formulary for the 2026 plan year; generic liraglutide is the covered agent source
  • Jul 1, 2026 NPF document lists Foundayo preferred; Zepbound KwikPens and vials excluded source
Criteria cited are Cigna National Formulary coverage policies (cnf_684, rev. 4/15/2026) used with ESI-administered Cigna business; the ESI NPF standard tracks these closely but self-funded clients customize. Widely-indexed secondary sources claim Wegovy injection, Wegovy tablets and Zepbound pens are excluded from the 2026 NPF and that Zepbound vials are the preferred agent — that is backwards, and both of ESI's own PDFs say so. NPE1702 (the covered PDL, effective Jan 1 - Dec 31 2026) lists FOUNDAYO, liraglutide, WEGOVY HD, WEGOVY PENS, WEGOVY TABLETS and ZEPBOUND PEN as covered; the exclusions document lists ZEPBOUND KWIKPENS and ZEPBOUND VIALS as the excluded items, with those same six as their preferred alternatives. Re-verified against both documents on 2026-09-02 (the file date stays 2026-08-26; see below), which still carry the PRMT22157-26 and EXCL-NPF-26 (07/01/2026) revision stamps. Trust the primary document. The cnf_684 PA document itself stopped resolving between 2026-08-26 and 2026-09-02: it now returns 404 from static.cigna.com, chk.static.cigna.com and v.static.cigna.com alike, to two independent clients, while its neighbours in the same directory (cnf_360, cnf_894, ip_0621) still return 200 — so the file was withdrawn or renumbered rather than the path moving, and search results still index the old URL. The PA criteria below therefore rest on the last reading of a document that is no longer published; nothing in them is contradicted by anything current, but they cannot be re-checked at that URL, and a replacement carrying the same BMI, duration and reauthorization criteria has not been found. cnf_894 is cited alongside it because it is live and carries the class-wide claim limit. That is the second unreadable citation on this file: the appeal block's 180 days, its Level-2 90 days and the St. Louis address rest on an hr.jhu.edu mirror that has now refused both clients with a Cloudflare 403 on three consecutive days (2026-08-31, 09-01, 09-02). Those two are why the file date stays 2026-08-26 while everything it cites that CAN be opened was re-read on 2026-09-02 — the date is a floor over the whole file, and two of its sources cannot be checked by anyone here. Both were retried on 2026-09-04 from an unblocked network outside this environment: cnf_684 returned 404 there too, and the hr.jhu.edu mirror served the same Cloudflare block, so neither is an artifact of this environment — the Cigna document is withdrawn rather than refusing us, and the JHU mirror refuses everyone. Do not swap in ip_0621 as the replacement: it is live, it indexes next to cnf_684 and it covers the same four drugs, but it is a benefit-exclusion-override policy (effective 2026-04-30) whose bar is BMI >= 32, so citing it would silently replace the >= 30 / >= 27-with-comorbidity criteria above with a stricter one. cnf_908 and cnf_915 are indexed as well and 404 from every Cigna host tried. Re-tested 2026-09-05: cnf_684 still 404s and the hr.jhu.edu mirror still returns a Cloudflare 403, so the file date stays here. cnf_950 has since appeared in search results and is the same trap as ip_0621 — its own filename says beo_encircle_bmi_35, so it is another benefit-exclusion-override at a BMI >= 35 bar rather than the standard PA criteria, and it 404s from static.cigna.com anyway. cnf_894 is the only one of these that has ever answered.
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.