in 84 days LillyDirect self-pay — Foundayo™ (orforglipron) 2.5 mg moves to $199/month See the changelog
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CVS Caremark

PBM standard commercial template · updated September 30, 2026

Coverage right now

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

DrugStatusDetailConfidence
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). sourcehigh
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. sourcehigh
Wegovy® (semaglutide injection)Preferred
from Jul 1, 2025
Preferred GLP-1 for obesity on template formularies since July 1, 2025; reaffirmed May 28, 2026. sourcehigh
Wegovy® tablets (oral semaglutide)Covered
from Jan 5, 2026
Covered with PA under the Wegovy criteria document (4774-C family). sourcemedium
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. sourcehigh
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). sourcemedium

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 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. The Zepbound OSA route sets its own bar instead: a CURRENT BMI >= 30 with no comorbidity alternative, plus a diagnosis of moderate-to-severe OSA at an apnea-hypopnea index of at least 15 events per hour on polysomnography or an adequate home sleep apnea test.
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. This is the weight-management route's requirement and the OSA route does not carry it: 6192-C asks the OSA request only for reduced-calorie diet and increased physical activity, with no prior-program duration at all.
Initial authorization
Zepbound 8 · Wegovy injection 8 for adults 18 and over, 7 for ages 12-17 · Wegovy HD 7.2 mg 8 · Wegovy tablets 6 (Zepbound-OSA 6; Wegovy-MASH 12, injection only; Wegovy-CV 12, injection and tablets). Continuation is 12 months in every case. Wegovy HD is the one product with only one door: 4774-C excludes it by name from the MASH and cardiovascular-risk criteria, so an HD request can be approved for weight management and nothing else.
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 HD 7.2 mg: 3 mL (4 single-dose pens)/21 days, 9 mL/63 days. Wegovy FlexTouch 2.4 mg is listed separately as a single-patient-use multi-dose pen at 3 mL (one pen)/21 days, 9 mL (three pens)/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) — Zepbound 6192-C at P08-2025, Wegovy 4774-C now at P08-2025 v5, which carries a 2026 copyright and a June 2026 package insert and is where Wegovy HD entered. If your plan is Caremark-administered but employer-customized, your criteria may differ — ask for the plan-specific criteria document in writing. The Zepbound document scopes itself to all dosage forms EXCEPT the single-dose vials, which it says are covered under the LillyDirect manufacturer program, yet its own quantity table still prices vials alongside pens; the two statements are not reconciled in the document and a member relying on vial coverage should get their plan's answer in writing. The 2025-07-01 switching statistic is the one claim here whose source cannot be reopened: managedhealthcareexecutive.com refuses every client from this network.
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.