GLP-1 Coverage by Pharmacy Benefit Manager: CVS Caremark, Express Scripts, and Optum Rx (2026)

If you have health insurance through an employer, a company you may never have heard of probably decides which weight-loss drug your plan prefers. That company is your pharmacy benefit manager, or PBM. The three biggest are CVS Caremark, Express Scripts, and Optum Rx.

Each one publishes "template" formularies, standard drug lists that employers can adopt as-is or adjust. Where Wegovy and Zepbound sit on those templates has changed more than once since 2025. This guide sets out where each PBM stands as of September 2026, what "preferred" means for you, and what to do if the drug you want is not the one your PBM prefers.

One rule runs through everything below: the PBM template is a starting point, not a guarantee. Your employer (or union, or health plan) chooses the template and can change it, including dropping weight-loss drugs entirely. For the bigger picture of who covers GLP-1s and why, see our GLP-1 insurance coverage guide.

What a PBM is and why it matters for GLP-1s

A pharmacy benefit manager runs the prescription drug side of a health plan. Employers, health plans, unions, and government bodies hire PBMs to negotiate drug prices with manufacturers and to manage the drug lists (formularies) their members use. CVS Caremark describes its role in exactly these terms in its May 2026 announcement.

For weight-loss GLP-1s, the PBM's formulary decisions matter in three ways:

• Preferred vs. non-preferred vs. excluded. A preferred drug usually has the lowest copay. A non-preferred drug costs more. An excluded drug is not covered at all unless you win an exception.
• Utilization management. Even preferred GLP-1s for weight loss nearly always need prior authorization, and many plans add step therapy and quantity limits.
• The plan's own choice. Whether your plan covers weight-loss drugs at all is usually the employer's decision, not the PBM's.

Preferred lists change. CVS Caremark, for example, tied its 2026 decision to add Zepbound back to negotiations with manufacturers that secured "more affordable costs."

How to find out which PBM you have

Start with your health insurance card.

1. Look for the pharmacy section. Most cards print RxBIN, RxPCN, and RxGroup numbers. These are the routing codes a pharmacy uses to send your prescription claim to the right processor. They tell the pharmacy where to send the claim; they do not tell you what is covered.
2. Look for a name or logo. Many cards show the PBM's name (Caremark, Express Scripts, Optum Rx) or a separate pharmacy help-line number.
3. If the card does not say, ask. Call the pharmacy number on the card, check your plan's member website, or ask your HR benefits team. Your pharmacist can also see which PBM processed your last claim.

Once you know your PBM, the next question is which formulary your plan uses. PBMs run several (Optum Rx alone publishes Select Standard, Premium, and others), so ask your plan or check its drug-list lookup tool for the name of yours.

CVS Caremark: Wegovy preferred since July 2025, Zepbound returns October 2026

CVS Caremark has made the biggest moves in this class, and its reversal is the change most likely to affect you this year.

July 1, 2025: Wegovy preferred, Zepbound removed. On May 1, 2025, Novo Nordisk announced that Wegovy would be the preferred GLP-1 for obesity on "the largest commercial template formularies for CVS Caremark," effective July 1, 2025. In a June 27, 2025 update, CVS Health confirmed: "On July 1, 2025, we will take a formulary action to prefer Wegovy and remove Zepbound" on its commercial template formularies.

The same CVS update said:

• Members with an active prior authorization for Zepbound would not need a new prior authorization to move to Wegovy.
• Members who had already tried Wegovy and had "severe or intolerable side effects" or "did not achieve sufficient weight loss" could request a formulary exception for a different weight-loss drug. CVS described this as a "case-by-case medical necessity review" that requires supporting documentation from the provider.

October 1, 2026: Zepbound added back. On May 28, 2026, CVS Health announced it will "add Zepbound back to our commercial formularies as an additional preferred option October 1, 2026." The word "additional" matters: Zepbound joins Wegovy as a preferred option rather than replacing it. The Boston Globe reported on May 29, 2026 that both drugs "will have the same copay," and both the Globe and NBC News put the number of people on the standard commercial template at roughly 25 million to 30 million.

June 1, 2026: Foundayo unblocked. The same announcement said that from June 1, 2026, Caremark would remove its new-to-market block on Foundayo (orforglipron), Lilly's oral GLP-1, "where approved for coverage by plans." For background on the drug, see our orforglipron guide.

What this means for you:

• If your plan uses a standard Caremark template, you should be able to fill Wegovy as preferred now, and Zepbound as preferred from October 1, 2026, subject to prior authorization.
• CVS says plan sponsors "retain discretion to customize coverage." NBC News noted that being on the formulary "does not guarantee the drugs will be covered by every insurance plan." Your employer may not adopt the Zepbound change, or may not cover weight-loss drugs at all.
• If you switched from Zepbound to Wegovy in 2025 and are doing well, nothing forces you to switch back. Any change is a conversation with your prescriber.

Weight-management program. CVS says it offers a weight-management program to CVS Caremark clients (employers and plans) that pairs medication with one-on-one clinical and lifestyle support. In its June 2025 update, CVS did not describe program enrollment as a condition of coverage. Whether your plan includes it, and whether it is required, depends on your employer.

Express Scripts: Wegovy and Zepbound single-dose pens preferred; vials and KwikPens excluded

Express Scripts (part of Evernorth) did not pick a single winner. Its template favors specific formulations.

January 1, 2026 changes. An Express Scripts notice dated August 2025 listed new weight-loss exclusions on its National Preferred Formulary (NPF) from January 1, 2026: Saxenda and Zepbound vials excluded, with Wegovy and Zepbound pens named as the preferred alternatives.

Mid-2026 exclusion list. The current 2026 NPF exclusions document (version dated July 1, 2026) lists these in the weight-loss class:

A note on the names: the Zepbound KwikPen is a multi-dose pen that holds a month of doses, which Lilly launched in February 2026. The Zepbound pens preferred here are the original single-dose auto-injectors. Wegovy HD is the 7.2 mg dose of Wegovy the FDA approved on March 19, 2026. If you use a KwikPen or vials bought through LillyDirect, the pharmacy benefit may not cover that form on this template, even though Zepbound single-dose pens are covered.

2027. Express Scripts' 2027 NPF drug list (effective January 1, 2027, and marked "subject to change") again lists Foundayo, Zepbound Pen, Wegovy HD, Wegovy pens, and Wegovy tablets.

Express Scripts states on its formulary documents that "not all the medications listed are covered by all prescription plans." If you are on an excluded drug and your prescriber identifies a clinical reason to stay on it, Express Scripts says your prescriber can request a coverage review through its portal at esrx.com/PA.

Programs tied to coverage. Express Scripts and Evernorth offer several optional programs that employers can add:

• EncircleRx. Evernorth's provider page says the program "includes coverage requirements for certain GLP-1 medications, including a lifestyle modification program." It lists Wegovy, Zepbound, Saxenda, and Foundayo, and gives coverage criteria of a BMI of 32 or higher, or a BMI of 27 or higher with two weight-related conditions. If your employer uses EncircleRx, you may need to take part in a lifestyle program to keep coverage.
• $200 monthly cap option (May 21, 2025). Evernorth announced a benefit option under which the monthly copay for Wegovy and Zepbound "will be limited to no more than $200" for members of plans that adopt it.
• Patient Assurance Program (July 10, 2025). Express Scripts said Wegovy and Zepbound were being added to this program for "participating health plans and employers." The release did not give a copay figure for the weight-loss drugs.

None of these is automatic. Ask your HR team whether your plan uses any of them.

Optum Rx: Wegovy and the Zepbound auto-injector on tier 2, with coverage set by your plan

Optum Rx's published 2026 template formularies treat the two major injectables similarly.

On both the 2026 Select Standard Formulary and the 2026 Premium Formulary (each effective January 1, 2026):

• Wegovy: tier 2 (preferred brand), prior authorization, quantity limit, and a "++" flag.
• Zepbound auto-injector: tier 2, prior authorization, quantity limit, "++".
• Saxenda: tier 2, prior authorization, quantity limit, "++".
• Zepbound vials: listed as excluded on the Premium Formulary.

The "++" flag is the key detail. Optum defines it as "Benefit design options – Coverage is determined by your prescription medication benefit plan." In plain terms, Optum's template allows these drugs, but your employer decides whether weight-loss drugs are covered at all.

NBC News reported on May 28, 2026 that Express Scripts and Optum Rx "already cover Zepbound," which fits these template listings.

Weight-management program. Optum Rx runs a program called Weight Engage for employers. In a May 7, 2026 SEC filing, Omada Health said it had joined "Optum Rx's Weight Engage portfolio to help employers expand responsible, clinically supported access to GLP-1 and other anti-obesity medications." Whether your plan uses Weight Engage, and whether it attaches conditions to coverage, is set by your employer.

Quick comparison (template formularies, September 2026)

Every row above comes with prior authorization, and your employer's choice sits on top of it.

What to do if your drug is not your PBM's preferred one

1. Confirm your plan's actual status. Before you change anything, look up your drug on your plan's own formulary tool or call the pharmacy number on your card. Ask three questions: Is it covered? Is it preferred? What prior authorization or step therapy applies? Get the answer in writing if you can.

2. Ask for a formulary exception. A formulary exception asks the plan to cover a non-preferred or excluded drug because the preferred one is not medically appropriate for you. Your prescriber usually files it. Strong requests typically document:

• A prior trial of the preferred drug, with dates and doses, that ended because of side effects or not enough response. This is the exact scenario CVS named in its 2025 guidance.
• A medical reason the preferred drug is not appropriate for you.
• The risk of switching if you are stable on your current drug.

Express Scripts points prescribers to esrx.com/PA for coverage reviews. For Caremark and Optum Rx, your prescriber can use the prior authorization process listed on your plan materials. If the exception is denied, you can appeal. Our step-by-step appeal guide covers denial letters, peer-to-peer reviews, and external review.

3. Talk to your prescriber about switching. For many people, the practical choice is whether to move to the preferred drug. Semaglutide (Wegovy) and tirzepatide (Zepbound) are different medicines with different trial results and side-effect profiles, and dosing does not carry over one-to-one. See Wegovy vs Zepbound for the trial data, and make any switch with your prescriber, who will set the starting dose. In 2025, CVS said a member with an active Zepbound prior authorization would not need a new one to move to Wegovy; check whether a similar rule applies to your plan.

4. Check the formulation. On Express Scripts' template, Zepbound single-dose pens are preferred while vials and KwikPens are excluded. Asking your prescriber to write for the covered form may solve the problem without changing drugs.

5. Know your cash fallback. If coverage fails or your plan excludes weight-loss drugs, manufacturer self-pay programs may cost less than your plan's non-preferred copay. Compare options in Wegovy without insurance, Zepbound cost, and our tirzepatide cash price guide.

6. Plan for open enrollment. Pharmacy benefits can change when your plan year renews. If you are choosing between plans, or your employer is reviewing its PBM, ask HR which formulary the plan uses and whether it covers weight-loss GLP-1s.

A note on Medicare and Medicaid

This page covers commercial (employer and individual) plans. Medicare Part D plans and state Medicaid programs follow different rules, even when a PBM administers them. See our Medicare GLP-1 coverage guide and Medicaid GLP-1 coverage guide.

The bottom line

As of September 2026, all three big PBMs list at least one Wegovy and one Zepbound product on their main commercial templates. What differs is which formulations are preferred, when changes take effect, and which add-on programs they sell to employers. The biggest date to watch is October 1, 2026, when Zepbound returns to CVS Caremark's standard templates. Still, your own plan's drug list decides what you pay. Check it, document your history with your prescriber, and use the exception and appeal routes when the preferred drug is not right for you.

This article is general information about insurance coverage, not medical advice. Decisions about which medication to take, or whether to switch, should be made with your prescriber.

Related coverage guides

• GLP-1 letter of medical necessity (with template)
• Zepbound prior authorization
• Wegovy prior authorization
• If your employer dropped GLP-1 coverage
• Ozempic and Mounjaro prior authorization for type 2 diabetes
• How to appeal a GLP-1 prior authorization denial
• Step therapy for Wegovy and Zepbound