Denied Zepbound by CVS Caremark? Learn how to appeal in 5 steps — including what to say, how to say it, and how to get help from Honest Care
Denied coverage for Zepbound by CVS Caremark? Starting July 1, 2025, CVS Caremark (a major pharmacy benefit manager) removed Zepbound from many formularies and requiring patients to switch to Wegovy or other alternatives. The good news is you have the right to appeal this decision – and win.
In the sections below, we’ll guide you through 5 steps to appeal your CVS Caremark Zepbound denial – including what to say, how to prepare supporting evidence, and how to submit your appeal for the best chance of approval.
Need Help Appealing? Explore Honest Care's GLP-1 appeal service.
Key Takeaway: If staying on Zepbound is important for your health, appealing is absolutely worth the effort. You have a legal right to fight for the treatment you deserve, and appeals of this kind often succeed.
Before diving into the how-to, take a moment to affirm why you should appeal instead of simply accepting CVS’s decision. In short, you owe it to your health to appeal. Here’s why:
According to a study analyzing data from several U.S. states, patients who appealed directly to their insurance provider (an internal appeal) experienced a success rate between 39-59%. If continuing Zepbound is important to you, those odds are worth taking a stand. Remember, you have the right to appeal any coverage denial under the law , and there is no penalty for trying. The worst outcome is that the denial is upheld – in which case you’re no worse off than now – but the best outcome is regaining coverage for the medication that works for you.
Under the Affordable Care Act, every health plan must offer an appeals process for denied treatments . In cases like this formulary change, federal regulations specifically protect your right to request a medically necessary exception to keep coverage for a drug not normally covered . CVS Caremark must allow and review your appeal, and if your doctor or you demonstrate that switching could harm you, they may be required to approve coverage as an exception.
Key Takeaway: Know the exact reason CVS Caremark gave for denying Zepbound. This will shape your appeal. In most cases for 2025, the reason is a formulary change – Zepbound was removed from the covered drug list in favor of alternatives like Wegovy. Identifying this (or any additional denial reasons) will help you target your appeal effectively.
To effectively appeal for Zepbound coverage, it is critical to understand why you were denied to begin with. Your insurance is obligated to provide you a written explanation on why you were denied, which is often referred to as the “Explanation of Benefits”.
Some common reasons for denial are:
This is the likely reason if you were told to switch to Wegovy. It means Zepbound is not on the list of medications your plan covers. In fact, CVS Caremark’s updated formulary lists Zepbound as “❌ Not covered,” while drugs like Wegovy, Saxenda, Qsymia, and Orlistat remain covered or preferred . The letter you received might say something like, “another covered medication is safe and effective for your condition and may cost less” . Essentially, CVS made Wegovy the preferred obesity drug and dropped Zepbound for cost reasons . If this is your denial reason, your appeal will be a formulary exception request – asking CVS to cover Zepbound for you due to medical necessity .
In some cases, if Zepbound were still on formulary but your plan has strict criteria, they might claim you don’t meet requirements (for example, not having a high enough BMI or required health condition). This reason is less likely with the current Caremark situation (since they’re outright excluding Zepbound on many plans), but if it appears, you would need to demonstrate why Zepbound is medically necessary for you. This could mean showing you do meet the criteria (BMI, etc.) or that your circumstances warrant an exception . Often, providing detailed medical history and a doctor’s letter can overturn a “medical necessity” denial.
Your plan might require trying other weight loss medications (like Contrave, phentermine, Orlistat, Qsymia, or even Wegovy) before approving Zepbound . With Caremark’s change, this effectively means they want you on Wegovy or another covered drug first. If you’ve already tried and failed one or more of those alternatives, or if there’s a medical reason you cannot use them, this is critical information for your appeal. You’ll need to document what happened with those treatments (e.g. “Tried Wegovy, but had severe side effects” or “Lost weight on Saxenda but regained it, whereas Zepbound has been effective”). Showing prior trials can rebut a step therapy denial. If you haven’t tried the alternatives due to valid concerns, have your doctor explain why Zepbound is a better or safer choice for you.
There is a chance that Zepbound was automatically denied because your insurance doesn’t cover weight loss medications as a category. You can appeal even if this is your insurance’s official policy. Insurance makes coverage decisions based on what will save the most money. Within your appeal, you can focus on how covering Zepbound now will save your insurance plan later. Read our guide on Weight Loss Plan Exclusion Denials.
For most patients reading this, CVS Caremark’s formulary change is the core issue – meaning your appeal will focus on why you need an exception to keep Zepbound despite it not being normally covered. But double-check all reasons given. Sometimes multiple factors apply (e.g. “Not on formulary” and “must try Wegovy first”). Address each in your appeal. Understanding the why behind your denial sets the stage for a successful argument to overturn it.
Key Takeaway: An appeal is won with evidence. Take time to gather personal medical records, documentation, and any proof that shows why Zepbound is medically necessary for you. This includes demonstrating your health conditions, past treatment history (especially any failures with alternatives like Wegovy), and the positive impact Zepbound has had. The goal is to build an evidence packet that justifies the exception. Need help? Honest Care can help you gather your Zepbound supporting evidence.
This is crucial. If you’ve already been on Zepbound (or Mounjaro/tirzepatide) for any period, gather records of:
List any prior medications you’ve used for weight or related conditions, especially if your plan has preferred drugs you were supposed to try first. Common ones include metformin (for insulin resistance), phentermine, Contrave, Qsymia, Saxenda, Wegovy, Orlistat, etc. . For each, note how long you took it and why it didn’t work or why you stopped:
This is a powerful piece of evidence. A Letter of Medical Necessity is basically your provider’s written explanation of why you need Zepbound specifically. It often includes much of the above information – your diagnoses, treatment history, and professional reasoning for choosing Zepbound. Only a qualified healthcare provider can write an LMN, but you can certainly prompt your doctor to include key points . For example, ask your doctor to explicitly mention if “Wegovy was not effective for this patient” or “due to the patient’s obstructive sleep apnea, Zepbound is clinically indicated and appropriate whereas alternatives are less ideal.” A strong LMN will detail your medical history, past weight-loss attempts/medications, and current progress on Zepbound . It basically backs up your personal appeal with a professional’s validation. If your doctor didn’t already submit an LMN with the initial prior authorization, definitely get one for the appeal . Many appeals are won on the strength of a doctor’s advocacy.
Gathering these pieces may seem daunting, but it’s basically pulling together the story of your weight loss journey and why Zepbound is the right fit. Think of your appeal as a package of proof: you want the decision-maker to see “This patient meets the criteria, has tried other avenues, and is doing well on Zepbound – it would be harmful or at least counterproductive to switch them.” The more documentation you have to support each part of that statement, the stronger your appeal.
Key Takeaway: Your appeal letter should clearly ask for a formulary exception for Zepbound, directly address the denial reason, and then summarize your case – why Zepbound is medically necessary for you – using the evidence from Step 3. This includes highlighting your health conditions, prior failures with alternatives, and the success you’ve had with Zepbound. An effective letter is structured, factual, and persuasive. Need help? Honest Care can write your appeal letter.
Now it’s time to put pen to paper (or fingers to keyboard). Writing an appeal letter can be intimidating, but by following a straightforward outline, you can cover all the important points. Here’s how to structure and what to include in your CVS Caremark Zepbound appeal letter:
Key Takeaway: Follow the instructions from CVS Caremark for submitting your appeal – whether that’s via mail, fax, an online portal, or through your doctor. Mark your appeal as urgent if your health could be at risk without Zepbound, as this can speed up the review (usually 72-hour turnaround by law ). Once submitted, keep track of timelines. Be prepared to follow up, and if needed, escalate with a second appeal or external review if the first decision is unfavorable. Persistence can pay off.
You’ve written a compelling appeal letter – now make sure it gets to the right place and triggers a proper review:
Finally, remember that Honest Care is in your corner throughout this process. If an appeal fails, we can help analyze the denial and strengthen your next attempt. We believe every denial should be challenged – because your health is worth fighting for.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments, because access to great healthcare is a human right.
Insurance companies purposely make this process convoluted and difficult to understand in order to deter decision challenges and protect their bottom line. That’s where we come in. We’re bridging the gap between insured individuals and their access to needed medications by creating a free customized insurance appeal letter. We’ll do all the hard work for you - you just need to include a few small edits, then you can send your appeal letter to your insurance provider through their outlined appeal process.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments we’ve made generating a strong appeal letter free.
We also offer paid services to access our team of GLP-1 experts. If you are not satisfied with our team's services, email our support team at support@findhonestcare.com and we will be happy to remedy any issues. You can also request a refund within 60 days of purchase of our services so long as your appeal hasn't been submitted to your insurance. Once our appeal packet has been submitted to your insurance, we will no longer issue refunds. Refunds are processed to the original payment method within 5 to 10 business days.
We help patients fight insurance coverage denials so they can get access to the medications and treatments they deserve. We currently specialize in insurance coverage denials for Ozempic, Mounjaro, Wegovy and Zepbound.
If you are denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, Honest Care can help fight your denial by submitting an ‘appeal’ to your insurance. An appeal is a formal request to your health insurance company to overturn their denial and grant coverage on your behalf. An appeal generally consists of a formal letter, addressed to your insurance, explaining why a medication should be covered on your behalf and why your insurance’s initial denial should be overturned.
You have the right to appeal to your insurance’s coverage denial. Honest Care simplifies the appeals process by writing an appeal letter and supporting documents on your behalf making your best arguments for medication coverage, following your completion of our proprietary GLP-1 denial assessment.
If your insurance denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, you have the legal right to ask your insurance to reconsider the coverage denial by sending an ‘appeal’. Unfortunately coverage denials too often go unchallenged. A study from September 2023 found that 69% of people who were denied coverage by their insurance didn’t know they could appeal, and 85% of people never tried to appeal.
We believe it always makes sense to appeal. Here is why:
Appeals work: According to a study analyzing data from several U.S. states, patients who appealed directly to their insurance provider (an internal appeal) experienced a success rate between 39-59%.
Denials are often issued by mistake: A computer almost always makes the initial decision to deny medication coverage. This results in denials that don’t actually consider your personal health situation or denials made by mistake. In the case of Ozempic, Mounjaro, Wegovy and Zepbound, incorrectly entered information about your BMI, labs including A1c, your health conditions and diagnoses, your medication history and current medication use can all lead to an automatic denial. When you appeal, your information is reviewed by a real person.
Doctors review appeals, not computers: Having a doctor consider your unique circumstances makes submitting an appeal a powerful process for overturning denials getting covered.
You deserve the best care: You have the legal right to fight the treatment you need. As a part of the Affordable Care Act, all health insurance plans are required to allow their members to appeal their coverage decisions. This spans all insurance coverage - whether you are insured through your employer, purchased an insurance plan through your state marketplace, or are insured through a government program like Medicare or Medicaid.
We currently offer appeal services for Ozempic, Mounjaro, Wegovy and Zepbound. After purchasing Honest Care and completing your online denial assessment, you can expect to receive your appeal letter within 2 business days.
1. Online denial assessment: Complete the online assessment at your convenience that gather all the necessary appeal evidence for your insurance. The assessment reviews your medication history, including any GLP-1s, weight loss or diabetes medications you have taken, your health conditions and diagnoses, your past weight loss, diet and exercise attempts, and details on your insurance coverage and denial.
2. Case evaluation & appeal strategy: One of our dedicated appeal specialist will review your assessment and insurance denial and identify your best appeal arguments for coverage. This will include an evaluation of your medication history, medical diagnoses, weight loss attempts and clinical research studies that strength your appeal case.
3. Appeal letter & supporting documents: Your assigned appeal writer will compose a professional appeal letter addressing your denial reason and detailing your case for coverage. We’ll create a supporting evidence report that further justifies your appeal letter, to send your insurance along with your appeal.
4. Specialist Consultation & Support: After you receive and review your appeal letter & evidence, your dedicated appeal specialist will be available to answer your questions. They will be available to make updates to your appeal, if required. You will also have the option to schedule a phone or video call at a time of your convenience to you speak to your dedicated appeal specialist.
5. Send your appeal: You can submit your appeal yourself or have your doctor submit your appeal on your behalf. Most insurance companies accept appeals by mail or fax. Instructions on how to submitted appeal will be included within the written explanation on why you initially denied medication coverage, sent at the time at you were denied.
An insurance appeal is a formal request you make to your insurance company, asking them to reconsider a decision about your claim. This could be when they've denied your claim, not paid enough, or made a decision you disagree with. The appeal is your chance to argue your case, showing them why their decision should be different. It involves submitting a well-structured letter, along with any supporting evidence like medical records or repair estimates, to make your case stronger.
An insurance appeal letter is your way of asking the insurance company to reevaluate a decision, such as a denied claim. It's essentially your argument in writing, explaining why you believe their decision should be different. This is a common document patients can use to advocate for themselves with their insurance to cover their medical costs even prior to being denied for a treatment.
This letter will include your policy details, specific decision you disagree with, and provide solid reasons and evidence (like weight loss efforts, past and present medications, labs, receipts etc) for your appeal. The letter should be clear, concise, and respectful, ending with a specific request for what you want your insurance to do.
You can submit an appeal letter directly to your insurance or through your health care provider as part of your insurance appeal process.
Insurance supporting evidence is the documentation or information you provide to back up your claim or appeal with your insurance company. It's the proof that supports your case, like medical history, diet and exercise efforts, medication history, or relevant medical studies. This evidence is crucial because it shows the insurance company why they should approve your claim or reconsider a decision they've made.
We provide 3 types of supporting insurance evidence.
(1) Appeal Evidence - is the information you provide when you disagree with your insurer's decision about a claim or coverage. This could include detailed medical records, letters from your doctor explaining the necessity of a treatment, or information about how a treatment is standard for your condition. This evidence is crucial for challenging a denial or underpayment of a claim. Our role is to help you gather and present this evidence effectively, ensuring it clearly supports your need for the treatment or service claimed.
(2) Prior Authorization Evidence - is required when your health plan needs you to get approval before it covers certain medications or procedures. This evidence typically includes medical records, lab results, and a detailed rationale about why this specific medication or procedure is necessary for your condition. Our service involves assisting you in compiling comprehensive and relevant documentation to justify the medical necessity, aiming to secure approval from your insurance company for the required treatment.
(3) Step Therapy Exclusion Evidence - is used when you need to bypass the 'step therapy' protocol of your insurance plan. This protocol usually requires trying less expensive treatments before more costly ones are approved. Exclusion evidence might consist of medical records showing previous treatment attempts and failures, clinical data indicating why standard treatments are unsuitable or harmful for you, and detailed explanations about the necessity of the specific, often more expensive, treatment. We help you collect and organize this evidence to make a compelling case to your insurer that the standard step therapy process is not appropriate for your situation, thereby aiming for an exemption.
Working with your regular doctor can increase your chance of insurance coverage in several ways, including:
Yes - your Honest Care Report can be submitted to any doctor, including doctors working with online, telehealth-based GLP-1 clinics. Taking the Honest Care Assessment before engaging with a telehealth services presents several advantages, including helping you save money.
By using Honest Care before engaging with a telehealth company, you’ll find out how likely you are to get a GLP-1 prescription and will receive guidance on any recommended steps to take before your GLP-1 appointment. This can save you money by avoiding paying subscription fees until you’re fully prepared for your telehealth appointment.
There are nearly 10 GLP-1 medications available in the United States. Currently three of those medications, Zepbound®, Wegovy® and Saxenda®, are FDA-indicated for weight-loss assistance. The FDA indicates that people with a BMI ≥ 30 kg/m2 OR people with a BMI ≥ 27 kg/m2 who have been diagnosed with at least 1 weight-related condition are eligible for GLP-1s.
All other GLP-1 medications, including Ozempic® and Mounjaro®, are currently FDA-indicated for people diagnosed with Type 2 diabetes.
While FDA-guidelines are critical for understanding GLP-1 eligibility, there are a number of other factors to consider for determining GLP-1 eligibility.
Additional eligibility criteria that Honest Care takes into account include:
Prior Authorization (PA) is a process run by insurance plans to determine how necessary a medication is. Most insurance plans require Prior Authorization (PA) before approving coverage for GLP-1s.
After your GLP-1 prescription is written, your insurance plan will notify your doctor if a PA is required and ask your doctor for additional documentation on why your medication is necessary.
If a PA is required, your insurance plan will ask your doctor to submit detailed information on your diet and exercise history, your past weight loss attempts, weight loss medications you previously tried, and any unique challenges that you face that make a GLP-1 medically necessary.
The Honest Care Report includes evidence requested by most insurance plans and can be submitted to your insurance during the PA process. During your appointment, your doctor can attach your Honest Care Report to your health record so it is submitted as supporting evidence to your insurance if Prior Authorization is required.
