The issue:
GLP-1s are no longer just about weight loss as they’re shaping the future of chronic condition management. Unfortunately, access remains a moving target with one recent change:
Effective July 1, CVS Caremark removed Eli Lilly’s Zepbound from its national formulary, favoring Novo Nordisk’s Wegovy as the sole preferred weight loss treatment.
While Wegovy leads in global sales, Zepbound has shown superior weight loss results and holds a distinct FDA approval for treating sleep apnea, a serious condition tied to:
- Cardiovascular risks (e.g., high blood pressure, heart disease)
- Metabolic disorders (e.g., type 2 diabetes)
- Neurological threats (e.g., stroke, cognitive decline)
- Worsening comorbidities (e.g., asthma, depression)
Key Impacts for Members:
Members who are currently prescribed Zepbound must now consult with their healthcare provider and decide to either:
- Pay out-of-pocket for Zepbound
- Switch to Wegovy
- Appeal for Tier 4 coverage (higher cost, limited success rate) if medically necessary
Members who switch from Zepbound to Wegovy may experience:
- Side effects from changes in titration schedules and new medication
- Potential temporary weight gain during the transition
- Changes in out-of-pocket costs
- Challenges related to access and availability of Wegovy
Although manufacturer coupons may offer temporary cost relief, they don’t replace full coverage.
Key Impact for Employers:
This move highlights the growing tension between cost containment, clinical nuance, and patient access, with significant implications for continuity of care.
For employers and plan sponsors covering weight loss medications through CVS Caremark, now is a critical time to evaluate how this change may impact your employees and to provide clear guidance and support. As GLP-1 coverage strategies evolve, plan sponsors must ask:
✔ Are we balancing financial stewardship with member outcomes?
✔ How do we protect choice in a clinically diverse population?
Next Steps:
Let’s talk about what’s next in GLP-1 coverage strategy. Optimatum Solutions can review your data to evaluate the impact of this change for your organization, support employee communication and ensure you create the necessary solutions for your employees.
About Optimatum:
Optimatum is a vendor management firm that focuses exclusively on the HR supply chain with turnkey solutions that improve the financial, operating performance, transparency and accountability of HR Benefit programs while still maintaining existing vendor relationships.
Our support of the HR workstream during the M&A lifecycle encompasses operational due diligence, day-one readiness and post day-one synergies. We assist sponsors in leveraging the aggregate purchasing power of their portfolio to capture value and drive margin expansion.