Will CVS Caremark Cover Zepbound in 2025? A Comprehensive Guide

As the demand for effective weight loss medications continues to rise, Zepbound (tirzepatide) has emerged as a game-changer for chronic weight management. Approved by the FDA for adults with obesity or those overweight with weight-related health conditions, Zepbound offers promising results when paired with a reduced-calorie diet and increased physical activity. However, its high list price—around $1,059.87 per month—means that insurance coverage is a critical factor in determining its accessibility for most patients. For those insured through plans managed by CVS Caremark, one of the largest pharmacy benefit managers (PBMs) in the United States, a key question looms: Will CVS Caremark cover Zepbound in 2025?

we’ll explore the current landscape of CVS Caremark’s coverage of Zepbound, analyze trends from 2024, and provide insights into what patients and healthcare providers can expect in 2025. We’ll cover everything from Zepbound’s clinical benefits to formulary changes, prior authorization requirements, cost considerations, and alternative options. While definitive predictions are challenging due to plan variability and evolving PBM policies, we’ll leverage available data from sources like Reddit discussions, Managed Healthcare Executive, and PSG Consults to offer a well-rounded perspective optimized for search engines and packed with actionable information.

Understanding Zepbound: What It Is and Why It Matters

Before diving into coverage specifics, let’s unpack what Zepbound is and why it’s generating buzz in the weight management space. Zepbound, developed by Eli Lilly, is a dual glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist. Administered as a once-weekly injection, it’s designed to help adults with a body mass index (BMI) of 30 or higher (obesity) or 27 or higher (overweight) with conditions like hypertension, type 2 diabetes, or dyslipidemia achieve sustainable weight loss.

Clinical trials have showcased Zepbound’s efficacy. According to Eli Lilly, patients on the highest dose lost an average of 48 pounds, while those on the lowest dose lost 34 pounds—compared to just 7 pounds for those on a placebo. These results position Zepbound as a powerful tool in combating obesity, a chronic condition affecting over 40% of U.S. adults and linked to serious health risks like heart disease and stroke.

However, efficacy comes at a cost. Without insurance, Zepbound’s list price can exceed $1,000 monthly, making coverage through PBMs like CVS Caremark essential for affordability. Eli Lilly offers a savings card program, reducing costs to as low as $25 for those with commercial insurance or $550 for those without coverage, but these discounts hinge on insurance policies—bringing us to the central question of CVS Caremark’s stance in 2025.

CVS Caremark: A Quick Overview

CVS Caremark is a leading PBM that manages prescription drug benefits for millions of Americans through employer-sponsored plans, health insurance providers, and government programs. As a PBM, CVS Caremark negotiates drug prices with manufacturers, designs formularies (lists of covered medications), and sets coverage rules like copays and prior authorization requirements. Whether Zepbound is covered under a CVS Caremark plan depends on its inclusion in the formulary, which can vary widely across plans and is subject to annual updates.

Understanding CVS Caremark’s coverage of Zepbound requires examining current trends, formulary changes, and the factors influencing PBM decisions—all of which we’ll explore below.

Current Coverage Trends: What We Know From 2024

To predict CVS Caremark’s coverage of Zepbound in 2025, we first need to look at its status in 2024. Anecdotal evidence from Reddit users and insights from industry sources like Managed Healthcare Executive provide a snapshot of the current landscape.

Positive Signs of Coverage

Many CVS Caremark plan holders report that Zepbound is covered, often with reasonable copays:

One Reddit user shared that after paying $550 out-of-pocket, their CVS Caremark plan began covering Zepbound in 2024, dropping their cost to $139 per month.
Another user noted their copay fell from $60 to $30 after a formulary update.
A third reported a $15 copay, highlighting the range of experiences under different plans.

These accounts suggest that CVS Caremark has been adding Zepbound to its formularies, particularly for plans that include weight loss medications. A December 2023 article from Managed Healthcare Executive noted that other PBMs, like Express Scripts and Cigna, added Zepbound to their preferred drug lists, hinting at a broader industry trend that CVS Caremark may be following.

Challenges and Variability

Not all experiences are positive. Some users report that their CVS Caremark plans either don’t cover Zepbound or impose barriers:

One user said their plan denied coverage entirely, forcing them to explore alternatives.
Another mentioned that coverage was limited to a 30-day supply, with no option for a cost-saving 90-day supply via mail order.
Prior authorization (PA) requirements are a recurring theme, with some users facing denials or delays.

This variability underscores a key point: CVS Caremark coverage isn’t one-size-fits-all. It depends on the specific plan, which is often customized by employers or insurers to balance cost and access.

Formulary Changes: How They Shape Coverage

CVS Caremark updates its formularies annually, adding new drugs, removing others, and adjusting coverage criteria. These changes can make or break access to medications like Zepbound.

2024 Updates

In 2024, CVS Caremark made notable formulary adjustments. According to PSG Consults, CVS Caremark excluded 16 drugs—mostly single-source brands—and added 18 new ones for 2025. While Zepbound wasn’t specifically mentioned, this pattern of swapping high-cost drugs for alternatives or new therapies suggests that its status could shift.

Cost Management Strategies

CVS Caremark has a history of prioritizing cost-effective options. In 2023, CVS Health launched Cordavis, a subsidiary focused on biosimilars to lower drug costs (PSG Consults). While Zepbound isn’t a biosimilar, this initiative reflects CVS Caremark’s broader goal of balancing innovation with affordability—a dynamic that could influence Zepbound’s coverage.

If CVS Caremark negotiates favorable pricing or rebates with Eli Lilly, Zepbound’s inclusion in 2025 formularies could expand. Conversely, its high list price might prompt exclusions in cost-sensitive plans, especially if cheaper alternatives emerge.

Prior Authorization: A Potential Hurdle

Even when Zepbound is on a CVS Caremark formulary, prior authorization (PA) is often required. PA ensures that a medication is medically necessary and aligns with plan criteria, but it can delay access and frustrate patients.

Typical PA Criteria

For GLP-1 agonists like Zepbound, CVS Caremark commonly requires:

A BMI of 30+ (obesity) or 27+ with a weight-related condition (e.g., diabetes or hypertension).
Documentation of a reduced-calorie diet and exercise plan.

Some plans may also enforce step therapy, requiring patients to try other weight loss drugs (e.g., phentermine) before approving Zepbound. Reddit users have reported mixed outcomes:

One user’s PA was denied because their plan mandated a six-month weight management program first.
Another successfully obtained approval after their doctor submitted BMI and comorbidity data.

Navigating PA

To improve approval odds, patients should work with their healthcare provider to submit thorough documentation. If denied, appealing the decision or exploring Eli Lilly’s savings card may be viable options.

Cost Considerations: Copays and Savings Programs

For those with CVS Caremark coverage, out-of-pocket costs vary:

Copays: Reported ranges include $15, $30, $60, and $139 per month, depending on the plan.
No Coverage: Without insurance, patients face the full $1,059.87 list price.

Eli Lilly’s Savings Card

Eli Lilly’s program offers relief:

With Coverage: As low as $25 for a one- to three-month supply.
Without Coverage: Around $550 monthly—half the list price but still significant.

This program can bridge gaps for patients with high copays or no coverage, though eligibility requires commercial insurance (not Medicare or Medicaid).

CVS Caremark’s Cost Strategy

CVS Caremark’s exclusion of hyperinflated drugs with alternatives (PSG Consults) suggests ongoing efforts to curb spending. If Zepbound’s cost remains a sticking point, coverage might be limited to plans willing to absorb its price tag.

Alternatives If Zepbound Isn’t Covered

If CVS Caremark doesn’t cover Zepbound or barriers like PA persist, alternatives exist:

Other GLP-1 Medications

Wegovy (semaglutide): Another injectable weight loss drug, though coverage varies similarly.
Saxenda (liraglutide): An older GLP-1 option that might be covered at a lower cost.

Generic Options

While Zepbound has no generic, older drugs like phentermine may be cheaper and covered, though less effective for many.

Lifestyle Changes

Diet and exercise remain foundational, though they may not match Zepbound’s results for severe obesity.

Providers can tailor recommendations based on insurance and patient needs.

Looking Ahead: Will CVS Caremark Cover Zepbound in 2025?

Predicting 2025 coverage involves weighing several factors:

1. Current Trends

The growing inclusion of Zepbound in 2024 formularies suggests momentum. As obesity gains recognition as a chronic condition, PBMs like CVS Caremark may expand coverage for effective treatments.

2. Formulary Updates

The 2025 changes (PSG Consults) will be pivotal. Zepbound’s clinical value could secure its place, but cost concerns might limit it to certain plans.

3. Negotiations

If CVS Caremark secures better pricing from Eli Lilly, coverage could broaden. Their Cordavis initiative signals a willingness to innovate in cost management.

4. Plan Variability

Even if Zepbound is on the standard formulary, individual plans may exclude it or add restrictions. Patients must verify their specific coverage.

5. Market Dynamics

New weight loss drugs or regulatory shifts could influence CVS Caremark’s decisions.

Best Guess

Based on 2024 trends, Zepbound is likely to be covered by many CVS Caremark plans in 2025, especially those prioritizing weight management. However, PA, step therapy, and plan-specific exclusions will remain challenges.

Practical Steps for Patients

To determine if your CVS Caremark plan will cover Zepbound in 2025:

Check Your Formulary: Contact CVS Caremark or your employer/insurer for the 2025 formulary, typically available late 2024.
Consult Your Provider: Prepare for PA by documenting BMI and comorbidities.
Explore Savings: Apply for Eli Lilly’s savings card if coverage is limited.
Plan Ahead: If denied, discuss alternatives like Wegovy or lifestyle programs with your doctor.

Conclusion: Navigating the Zepbound Coverage Landscape

CVS Caremark’s coverage of Zepbound in 2025 remains uncertain but promising. Current trends lean toward inclusion, driven by Zepbound’s efficacy and growing demand for obesity treatments. Yet, variability across plans, PA hurdles, and cost considerations mean that access won’t be universal.

For patients and providers, staying proactive is key—check formularies, prepare for PA, and leverage savings programs as needed. As the PBM landscape evolves, resources like Managed Healthcare Executive and PSG Consults will remain vital for tracking updates. Whether CVS Caremark fully embraces Zepbound in 2025, one thing is clear: its role in weight management is here to stay, and coverage will shape its reach.