What You Need to Know: Navigating Zepbound Coverage Changes with CVS Caremark

Important Update: Zepbound Coverage Changes with CVS Caremark as of July 1st
What this means for you and how we’re helping you stay on track

If you’re currently taking Zepbound (tirzepatide) and have pharmacy benefits through CVS Caremark, please be aware of a significant change:

As of July 1st, Zepbound is no longer considered a preferred medication under most CVS Caremark plans.

However, some employer- or insurer-specific plans have chosen to continue covering it so coverage is now highly individualized and may vary based on your specific benefits package.

We understand this can be both frustrating and confusing. We are here to guide you through the steps, depending on your treatment history and insurance coverage.

If You’ve Never Tried Wegovy:

CVS Caremark requires that you attempt Wegovy first.
We will submit a prior authorization for Wegovy on your behalf.

If You’ve Tried and Failed Wegovy (or Had an Adverse Reaction):

You may still qualify for tirzepatide treatment, but the process involves multiple steps.

Step 1:

We will submit a new prior authorization for Zepbound (tirzepatide).
This will likely be denied, but the denial is necessary to initiate a formal exception.

We will then submit more supporting documentation such as a Letter of Medical Necessity, explaining your medical need for tirzepatide rather than Wegovy. We may include supporting documentation such as:

• Documented adverse reactions to Wegovy

• Co-existing conditions like obstructive sleep apnea (OSA)

• Evidence of significant progress, such as 5% or more weight loss on Zepbound (tirzepatide)

Step 2:

If the first prior authorization appeal is approved, CVS Caremark is currently covering Mounjaro (tirzepatide) even for patients without Type 2 diabetes.

Step 3:

If the first prior authorization appeal is denied, we will move forward with a formal appeal.

Why One Drug Is Covered While the Other Isn’t?

This coverage decision isn’t based on clinical effectiveness it comes down to formulary contracts between pharmacy benefit managers (PBMs), insurers, and drug manufacturers.

According to the Commonwealth Fund, PBMs use formulary placement as a negotiation tool to secure better pricing and rebates from pharmaceutical companies. 

Understanding Tirzepatide: Mounjaro vs. Zepbound

Zepbound and Mounjaro are both brand-name medications containing tirzepatide, a dual GIP/GLP-1 receptor agonist. While they are chemically identical, they are approved for different conditions:

• Mounjaro – FDA-approved for Type 2 diabetes management

• Zepbound – FDA-approved for chronic weight management

Although the ingredients are the same, the FDA-approved uses differ, which significantly impacts how insurance plans determine coverage. Because of formulary decisions, Mounjaro is now often covered in place of Zepbound, even for weight management.

If You Are Temporarily Off Medication:

• It is safe to pause your weekly dose for up to two weeks.

• You can resume your previous dose once the medication becomes available again.

• No tapering is necessary, and there are no withdrawal effects.

• Some patients may notice an increase in appetite or hunger during the gap, which is expected and manageable.

Your Care Is Our Priority. Even When the System Makes It Hard

We are working diligently to advocate for your access to the medication that best supports your health goals.

Unfortunately, CVS Caremark’s coverage policy is currently the rate-limiting factor. This may continue to evolve, so please stay in touch with our team for the most up-to-date guidance tailored to your insurance.

If you have questions about your coverage or next steps, please reach out to us directly.

We’re committed to helping you maintain continuity in your care.

Warmly,

Dr. LaRocca and the LaRocca Medical Team

Not a Current Patient? Here’s How You Can Take Action:

If you're not currently a patient at our practice but are affected by these changes, you still have options:

• Speak with your current primary care provider or specialist about your medication history and the insurance steps outlined above.

• Make sure they document any past adverse effects or lack of success with Wegovy, and include supportive diagnoses like obstructive sleep apnea or metabolic syndrome if applicable.

• Ask whether they can initiate the appeal process on your behalf if Zepbound was effective for you.

If you’re looking for a provider who offers personalized weight management plans and takes the time to advocate for your care, we invite you to learn more about how we work.

At LaRocca Medical, we offer individualized care plans, a focus on sustainable results, and a collaborative approach to weight loss that prioritizes both effectiveness and your long-term well-being.

Interested in becoming a patient?
You can schedule a free consultation to see if our approach is the right fit for your goals.