If you’re one of the many patients stunned by a recent denial of your Zepbound® prescription through CVS Caremark, you’re not alone. This blog will break down exactly what’s going on, what it means for you, and what your options are—plus some insider tips from our team at Life IV Weight Loss.
Last Updated on July 8, 2025 by justin@lifeivtherapy.com
What Is a Formulary?
A formulary is the list of medications your insurance plan agrees to cover. If a medication isn’t on the list, it’s considered non-formulary, which means your insurance won’t pay for it unless there’s a compelling reason or successful appeal.
Insurance companies rely on a group called a Pharmacy Benefit Manager (PBM) to create and manage these formularies. CVS Caremark is one of the largest PBMs in the country.
According to CVS Caremark’s official site, they routinely update their drug list based on clinical and economic evaluations.
Why Zepbound® Was Removed from CVS Caremark’s Formulary
As of mid-2024, CVS Caremark removed Zepbound® from its list of preferred drugs. If you’re prescribed this medication for weight loss, your insurance will now likely issue an automatic denial unless you meet certain strict criteria.
“Your plan does not cover this drug… The primary covered drug for your plan is Wegovy®. If you have tried the primary covered drug, another option for you is a tirzepatide product that has the same active ingredient at the same strength and dosage as the requested drug.” — CVS Caremark Denial Notice
Understanding Tirzepatide: Mounjaro® vs. Zepbound®
Zepbound® and Mounjaro® are both name-brand medications containing tirzepatide, a dual GIP/GLP-1 receptor agonist. However, they’re approved for different things:
- Mounjaro® – FDA-approved for Type 2 diabetes management
- Zepbound® – FDA-approved for chronic weight management (weight loss)
So while the ingredients are the same, the FDA labeling and approved uses differ, which plays a huge role in how your insurance decides to cover it.
Can You Use Mounjaro® Instead?
Technically, yes—but there’s a catch. Mounjaro® is only covered if you have a Type 2 diabetes diagnosis. If you’re taking tirzepatide solely for weight loss, your insurance may deny coverage for Mounjaro® as well unless you have qualifying conditions.
This leaves most patients stuck between a rock and a hard place: Zepbound® is denied, and Mounjaro® is inaccessible unless you’re diabetic.
Insurance Games: Why One Drug Is Covered, But Not the Other
This comes down to formulary politics and deals between PBMs, drug manufacturers, and insurers. According to the Commonwealth Fund, PBMs use formulary placement as leverage to negotiate lower prices and rebates from drug companies.
In this case, it appears Wegovy® (semaglutide) secured a better formulary position than Zepbound® for 2024 and beyond.
Can You File an Appeal?
Yes! If you or your provider believes that Zepbound® is medically necessary—and that Wegovy® is not a suitable alternative—you can file an appeal with your insurance.
What You’ll Need to Appeal a Zepbound® Denial:
- A detailed letter of medical necessity from your provider
- Documentation of any previous attempts (and failures) with Wegovy®
- Supporting labs, diagnosis codes (like BMI or obesity-related conditions), and progress notes
For the best chance of approval, your provider should clearly state why Zepbound® is the most appropriate and effective option for your health needs.
What If You Have Sleep Apnea?
We reached out to Zepbound’s support team to ask if Obstructive Sleep Apnea (OSA) can justify use. Their response was vague but suggested you can appeal with documentation—especially if you have a recent sleep study confirming your diagnosis.
It’s not a guarantee, but it’s worth trying. Many insurance companies will require evidence that the patient cannot tolerate or has failed other treatments before approving Zepbound®.
What Are Your Options Now?
Option 1: Try Wegovy® (Semaglutide)
This is CVS Caremark’s current preferred weight loss drug. While it has shown great effectiveness in clinical trials, not all patients respond the same. Some report different side effects or weight loss plateaus compared to tirzepatide-based medications.
Learn more about Wegovy® on the official prescribing info page.
Option 2: Pay Out-of-Pocket
Fortunately, if you don’t qualify under your plan, the retail cost of Zepbound® is $499 per month via their self-pay program. Learn more about the Zepbound® Vials their self-pay option on our webpage.
How Life IV Weight Loss Helps You Navigate Insurance Chaos
When insurers and PBMs change their rules, it’s the patient who suffers. That’s why our team goes above and beyond to help.
- We submit and track your prior authorizations.
- We assist with appeal letters and documentation.
- We offer affordable alternatives when insurance lets you down.
Most importantly, we treat you like a person, not a transaction. We’re not a faceless app. We’re a team of real providers, dietitians, and support staff who care about your journey.
Real Talk: Why Are These Drugs So Expensive Anyway?
Weight loss medications are booming, with drugs like Wegovy® and Zepbound® expected to generate over $100 billion globally by 2030, according to Wall Street Journal.
This explosive demand drives up prices—and insurance companies are pushing back by limiting coverage, even when clinical evidence shows the benefits of sustained weight loss on chronic disease.
Need Help? Contact Us Today
If you’re a client of Life IV Weight Loss or want to become one, schedule a visit or call us at (517) 273-3210. We’ll review your case, recommend the best course of action.