Lead
CVS Caremark will restore coverage for Eli Lilly’s weight-loss drug Zepbound this year, the drugmaker said Thursday, reversing a removal that drew patient complaints and a class-action lawsuit. The drug is scheduled to return to CVS Caremark’s standard formulary by Oct. 1, and some privately insured patients could see copays as low as $25. The move also adds Foundayo, Lilly’s weight-loss pill approved in April, to the same list starting Monday. CVS Caremark says the change affects its standard formulary population of roughly 25 million to 30 million people.
Key takeaways
- CVS Caremark removed Zepbound from its formulary last year; Lilly announced the drug will be reinstated by Oct. 1, 2026.
- Zepbound’s list price is $1,086 per month; Lilly offers cash discounts, but patients can still face hundreds of dollars monthly out-of-pocket.
- Lilly says some privately insured patients could pay a copay as low as $25 after reinstatement.
- Foundayo, a Lilly weight-loss pill approved in April, will be added to CVS Caremark’s standard formulary starting Monday.
- The formulary change applies to CVS Caremark’s standard list, which covers an estimated 25–30 million lives; employer plan decisions can still limit coverage.
- Express Scripts and Optum Rx — two other major PBMs — already list Zepbound as covered.
- A class-action lawsuit challenging CVS Caremark’s earlier removal was filed in September and remains active.
Background
Pharmacy benefit managers (PBMs) such as CVS Caremark play a central role in determining which medicines millions of Americans can access through insurance and how much patients pay at the pharmacy counter. Formularies are the PBMs’ tool for steering utilization, negotiating discounts and placing drugs into tiers that affect copays and prior-authorization rules. Disputes over formulary decisions have become more visible as high-cost specialty drugs — particularly GLP-1 related weight-loss treatments — gained popularity and media attention.
Eli Lilly’s Zepbound is a weight-loss medication with the same active ingredient as its diabetes drug Mounjaro; the diabetes indication remained unaffected by last year’s formulary changes. The class of drugs that includes Zepbound, Wegovy (manufactured by Novo Nordisk) and other GLP-1-based therapies has prompted debates among insurers, employers and patient groups about affordability and appropriate utilization. Employers and plan sponsors often have the final say on which formulary drugs they will reimburse, meaning PBM listing is influential but not dispositive.
Main event
Last year CVS Caremark removed Zepbound from its covered drug list, a step that led some patients to say they were forced to switch to alternatives such as Novo Nordisk’s Wegovy despite reporting better outcomes on Zepbound. Patient complaints and public attention followed the removal, and a class-action suit was filed in September contesting CVS Caremark’s decision. The case remains active as of this report.
On Thursday, Eli Lilly announced that Zepbound will be placed back on CVS Caremark’s standard formulary effective Oct. 1. The company also said Foundayo, approved in April, will be added beginning Monday. A CVS Caremark spokesperson confirmed the change applies to its standard formulary and provided the 25–30 million covered-lives estimate tied to that list.
The listing change is expected to expand the potential for insured access but does not automatically guarantee coverage for every plan member. Employers and health plans can carve out drugs, apply utilization management or impose different cost-sharing rules. Lilly noted that some privately insured patients could face copays as low as $25, though individual cost will depend on plan design and any negotiated pharmacy pricing.
Analysis & implications
Restoring Zepbound to CVS Caremark’s formulary reduces one barrier to access for many patients who had complained about forced switches; it may also blunt some litigation pressure tied to the September class-action filing. However, the practical impact on individual patients will vary because employer-sponsored plans retain discretion to set their own coverage rules. For patients on plans that follow CVS Caremark’s standard formulary, the change should increase the likelihood of coverage and potentially lower out-of-pocket costs.
For PBMs and drugmakers, this episode highlights the commercial and reputational risks of formulary decisions in a politically and media-sensitive area like weight-loss drugs. PBMs negotiate rebates and placement in exchange for preferred positioning; manufacturers seek broad formulary placement to drive uptake and secure real-world data. Public pushback and litigation can reshape those negotiations, creating incentives for companies to seek clearer communication and more predictable criteria for removals.
From a market perspective, Zepbound’s reinstatement narrows a competitive gap: Express Scripts and Optum Rx already covered the drug, and CVS Caremark’s return may neutralize a coverage advantage those PBMs held. Insurer cost exposure could rise if broader coverage increases utilization, putting more pressure on payers and employers to refine utilization-management strategies or seek larger manufacturer concessions.
Comparison & data
| Entity | Coverage status | Estimated covered lives |
|---|---|---|
| CVS Caremark (standard formulary) | Reinstating Zepbound by Oct. 1; adding Foundayo Monday | 25–30 million |
| Express Scripts | Already covering Zepbound | Major PBM — nationwide plans |
| Optum Rx | Already covering Zepbound | Major PBM — nationwide plans |
The table above summarizes coverage positions across the three largest PBMs. While CVS Caremark’s standard formulary change expands potential access to 25–30 million people, actual patient-level coverage depends on employer and plan selections. Zepbound’s list price is $1,086 per month, a figure that shapes negotiation leverage for PBMs and cost-exposure calculations for payers.
Reactions & quotes
“Zepbound will return to CVS Caremark’s formulary by Oct. 1,”
Eli Lilly (company statement)
That statement framed Lilly’s announcement of reinstatement and was presented as the company’s timeline for the drug’s return. Lilly also highlighted potential copay reductions for some privately insured patients, which it said could be as low as $25.
“The change applies to our standard formulary and affects roughly 25 million to 30 million people,”
CVS Caremark spokesperson
CVS Caremark attributed the metric to its standard formulary population and clarified that employer plan choices determine final coverage for individual members. The spokesperson confirmed the planned timing for both Zepbound and Foundayo additions.
Unconfirmed
- The precise commercial terms or rebate arrangements that led to Zepbound’s original removal from CVS Caremark’s formulary were not disclosed.
- The fraction of the 25–30 million standard-formulary lives who will actually have low copays (for example, $25) under specific employer plans is not publicly available.
- Whether the class-action lawsuit will lead to settlement or further changes in PBM behavior remains unresolved.
Bottom line
CVS Caremark’s decision to reinstate Zepbound reduces a major access barrier for many patients and represents a pragmatic reversal after public pushback and litigation. While the reinstatement expands the pool of plan members who may obtain the drug, coverage will still depend on employer-plan choices and any utilization-management policies those plans impose. The change may ease patient transitions for some, but high list prices — $1,086 monthly — and variable out-of-pocket costs mean affordability concerns are likely to persist for others.
For the broader market, this episode underscores how public scrutiny, legal challenges and commercial negotiations can tilt PBM formulary decisions. Observers should watch whether the reinstatement changes utilization patterns, influences employer plan design, or prompts similar coverage shifts across other PBMs and manufacturers in the rapidly evolving weight-loss drug market.
Sources
- NBC News — National news outlet reporting Lilly and CVS Caremark announcements (media)