PBM formulary GLP-1 teardown — who covers Wegovy and Zepbound in 2026

At-a-glance: 2026 coverage stance

“PA” = prior authorization. Member counts are commercial + Medicare Part D covered lives per DrugChannels 2024 estimates. Formulary status can change quarterly — verify the current PDL at the source link in each PBM section below.

The five PBMs, one at a time

1. CVS Health · ~90M covered lives

   CVS Caremark

   Wegovy stance — On formulary at higher-tier placement; prior authorization required documenting BMI ≥30 (or ≥27 + comorbidity) plus a prior lifestyle-intervention attempt.

   Zepbound stance — On formulary at higher-tier placement with prior authorization. Some employer plans exclude via formulary-exclusion list.

   PA signature — Standard CVS Caremark PA form requires BMI, comorbidity list, prior lifestyle-intervention documentation, and prescriber attestation. Typical approval turnaround: 3-5 business days.

   2024-2026 headline — In May 2025, Novo Nordisk struck a preferred-status agreement with CVS Caremark for Wegovy that lowered net cost per script — reflected downstream in more employers keeping Wegovy on formulary.

   Current formulary source

2. Cigna (Evernorth) · ~75M covered lives

   Express Scripts

   Wegovy stance — On formulary at higher-tier placement with prior authorization. Step-therapy through metformin or a first-line non-injectable is common for the obesity indication.

   Zepbound stance — On formulary at higher-tier placement with prior authorization. Step-through Wegovy or a semaglutide product is required by some employer plans before Zepbound approval.

   PA signature — Express Scripts PA typically requires BMI, comorbidity, prior trial of a lifestyle program, and (increasingly for Zepbound) prior semaglutide trial. Turnaround: 2-5 business days.

   2024-2026 headline — In 2024, Express Scripts launched an "EncircleRx" GLP-1 management program that adds outcomes-based rebate contracting for employers. Direct employer impact on approvals is uneven — some see broader access, others tighter step-therapy.

   Current formulary source

3. UnitedHealth Group · ~66M covered lives

   OptumRx

   Wegovy stance — Generally on the standard commercial formulary with prior authorization. UHC employer plans vary — Medicare Advantage plans typically do not cover for weight-loss.

   Zepbound stance — Removed from the national OptumRx Premium commercial formulary effective July 1, 2025 — replaced by preferred-status Wegovy. Some employer plans opted out of the exclusion, but for most UHC-covered members Zepbound is no longer a covered obesity option in 2026.

   PA signature — OptumRx PA requires BMI ≥30 or ≥27 + comorbidity, documented lifestyle attempt, and (for Wegovy) prescriber attestation that Zepbound is not the appropriate alternative.

   2024-2026 headline — OptumRx dropped Zepbound from the Premium formulary July 2025 — a national precedent-setting exclusion. Novo Nordisk-UnitedHealth preferred-status agreement is the driver. Employers may still elect a custom formulary that includes Zepbound.

   Current formulary source

4. MedImpact Healthcare Systems · ~55M covered lives

   MedImpact

   Wegovy stance — Formulary status varies by plan sponsor — MedImpact is a pass-through PBM that lets each health-plan client set its own formulary. Standard PA rules apply where covered.

   Zepbound stance — Formulary status varies by plan sponsor. Some state Medicaid MedImpact plans exclude weight-loss GLP-1s entirely.

   PA signature — MedImpact PA is administered per plan — approval criteria and turnaround depend on the underlying health plan, not MedImpact itself. Confirm with your health-plan card.

   2024-2026 headline — MedImpact is the primary PBM for several state Medicaid contracts (including AZ, HI). Coverage decisions in those markets track the state Medicaid weight-loss coverage rule rather than a national MedImpact formulary.

   Current formulary source

5. BCBS-owned (14 Blues plans) · ~30M covered lives

   Prime Therapeutics

   Wegovy stance — On formulary with prior authorization at most participating Blues plans. Step-therapy documentation is required by roughly half of participating plans.

   Zepbound stance — On formulary with prior authorization at most participating Blues plans. Coverage may be tighter than Wegovy at some plans as of 2026 — verify with your Blues card.

   PA signature — Prime PA forms follow each Blues plan customization. Typical: BMI + comorbidity + 3-6 months prior lifestyle attempt.

   2024-2026 headline — Prime is the outlier that has maintained relatively stable GLP-1 obesity coverage across 2024-2026 — no national exclusions similar to the OptumRx Zepbound decision.

   Current formulary source

If your PBM excludes or step-restricts your drug

1. Ask your employer for a formulary override. Employers can — and increasingly do — negotiate custom formularies that override the PBM default. If OptumRx's Premium exclusion of Zepbound blocks your prescription, your HR benefits team has the authority to request a plan-level override for the obesity category. This is the first call, not the last.
2. File a formulary exception request. Every PBM has a process to request coverage of an excluded drug when the covered alternative is clinically unsuitable — typically requires a prescriber letter of medical necessity documenting why the covered drug is not appropriate. Approval rate for well-documented obesity exception requests runs ~30-45% (unpublished PBM industry data, cross-referenced with KFF appeals research).
3. Use manufacturer savings + cash-pay path. Wegovy $499/mo via NovoCare and Zepbound $349-499/mo via LillyDirect run entirely outside the PBM system. See lower your GLP-1 cost for the full playbook.

Frequently asked

Sources

• Reuters — OptumRx drops Zepbound from Premium formulary (May 2025)
• Fierce Healthcare — Express Scripts EncircleRx launch (2024)
• CVS Health investor materials — Wegovy preferred agreement (2025)
• DHR — PBM market share estimates 2024
• Formulary status verified against each PBM's public PDL as of 2026-07-17. PBM member-count estimates from Drug Channels Institute (2024). Quarterly PBM formulary changes are common — refresh triggered by any documented national inclusion/exclusion event.