CVS Caremark Zepbound Exception Requests

CVS Formulary Update: Zepbound Coverage Discontinuation

Effective Date of Change: July 1, 2025

This article outlines the critical changes to the CVS Caremark formulary, the impact on members currently prescribed Zepbound, and the detailed workflow for handling transition and exception requests. These cases must be escalated to the PSG team for review. Because approval requires a formal clinical review process, please do not make any promises to the member, approve the request, or direct the member back to their provider.

I. Overview and Client Impact

Detail	Status
Medication Discontinued	Zepbound (for weight management) will no longer be covered on any CVS formulary.
Preferred Alternative	Wegovy is the preferred GLP-1 for weight management. Saxenda remains on the formulary.
Effective Date	July 1, 2025
Member Communication	CVS Caremark has already sent communications to impacted members

Impacted Vida Clients

Client Name	Client Name	Client Name
Schnucks	Onvida	Danaher
Nuvance	First Energy	Amrize
Bunzl Distribution	Group Insurance Commission of MA (GIC)	Ingram Micro
Arvest Bank	Aalberts Integrated Piping System	Swift Transportation

II. Agent Guidance: Member Inquiries & Actions

1. General Formulary Questions

Action: Do NOT provide formulary details. Route members to CVS Customer Support (number located on the back of their benefits card) for all general drug formulary and coverage questions.

2. FAQ: Transition Talking Points

Member Question	Approved Vida Talking Point
Why do I have to switch?	CVS Caremark has updated its formulary and will no longer cover Zepbound. Wegovy is now the preferred GLP-1.
Is the new drug better?	Both are GLP-1 medications that support weight loss. The choice to prefer one reflects formulary strategy and clinical assessment, not necessarily that one is better. Your provider will guide the change.
What should I expect during transition?	Side effects and dosing may differ. Our providers will work with you on the right timing for the switch based on your current schedule and tolerance.
What if I want to cancel Vida?	Check-in with member. Reassure them that Vida will help transition them to a covered drug (Wegovy or Saxenda). Advise them that remaining in Vida provides lifestyle support and seamless medication management through the change.
Reference to a Lilly Text?	The formulary change is a global CVS Caremark decision impacting all employers who use their PBM. Our prescribing aligns with the formulary; Zepbound is no longer covered by the pharmacy benefit plan.

3. Member is NOT w/ a Vida Prescriber (Dell / Use Case 2)

Response: Redirect clinical management to the current prescriber but offer Vida support/transfer.

Core Message: "Your current doctor is the right person to manage your transition (new prescription and dosing). You can use Vida's coach/dietitian support for lifestyle guidance during this change. It is also possible to transfer your medication management to a Vida Medical Provider. This requires information review and will take at least a couple of weeks to schedule the first appointment."

III. Exception Process and Workflow (For T1/MA Teams)

This process is for members seeking to remain on Zepbound despite the formulary change. All initial requests should be assigned to the Prescribing Support Group (PSG) as OPEN.

1. Exception Criteria Highlights

The criteria for an exception are strict and require documentation from the prescribing doctor.

Criteria (Must meet one of these)	Requirement
Wegovy Trial Failure	Tried branded Wegovy for at least 12 weeks, and either failed to lose more than 5% of body weight or plateaued.
Intolerable Side Effects	Experienced intolerable side effects on Wegovy, confirmed by prescriber.
Sleep Apnea	Diagnosed with moderate to severe Obstructive Sleep Apnea (Apnea-Hypopnea Index (AHI) via a valid sleep study. (No sleep study date restrictions)

2. Exception Request Initiation ( T1 &T2)

Action: Run the macro Prescribing support > Escalation > Exception request.
The macro will guide you through the following workflow:
Step 1 (Input): The macro prompts you to fill out the PSG Escalation Template.
Step 2 (Reply): It automatically generates the member reply using the Wegovy/Zepbound Exception Request verbiage.
Step 3 (Routing): It triggers the Internal Prescribing Team escalation logic, assigning the ticket to PSG with a status of OPEN.

3. Post-Decision Communication & Action

PSG will communicate the decision directly to the member via email or chat this is just to provide insight on that process, not action for MS agents to take

Status	Vida Prescriber Action	Member Notification
GRANTED (Charter, NG, Nuvance)	VMP is cleared to prescribe Mounjaro (or Zepbound for Dell/LA/MS) at the next consult.	Send Snippet C/D (Mounjaro/Zepbound Granted).
GRANTED (CVS, Swift,)	VMP is cleared to prescribe Mounjaro (or Zepbound for Dell/LA/MS) at the next consult.	Send Snippet C/D (Mounjaro/Zepbound Granted).
NOT GRANTED (Charter, NG, Nuvance)	VMP P2P Note: "Does not meet criteria. Transition to Wegovy or review other treatment options."	The Clinical Assistants send the member all communication in chat- grants and denials for both internal reviews and CVS exceptions sends the official denial email stating they do not qualify and advising they schedule a consult.
NOT GRANTED (CVS)	VMP P2P Note: "CVS did not grant. DO NOT prescribe tirzepatide. Review options for alternative medications."	Send denial message: Advise member to contact CVS support line for details and schedule a consult with VMP for alternative meds.

Crucial Dell-Specific Note

Effective 8/7/2025: All Dell exception scripts will be for Zepbound (Mounjaro is removed as the preferred tirzepatide exception). Any exceptions granted before August 7th require a switch from Mounjaro to Zepbound on the next fill.

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