CWA 1103 Members-VZ

As many of you know, Zepbound was removed from CVS Caremark's Formulary on July 1, 2025. Members and prescribers were notified of this formulary change and covered alternatives in the first week of May. Additionally, OneTouch test strips and kits for diabetes blood sugar testing, along with other drugs, were also removed.  These changes aren’t about what’s best for you or effectiveness. It’s about money. Pharmacy Benefits Manager’s (CVS Caremark) negotiate rebates with drugmakers, and these shady deals often determine which medication you can get –even if others are best for you.

How can this happen?  The CVS Caremark Formulary is dynamic.  A dynamic formulary is not new to our Agreements (CWA-VZ) and it is common for employers providing drug coverage to their employees.  The previous PBM, Express Scripts' Formulary, was also dynamic and there were changes in drug coverage during the year and during the life of the CBA (good and bad) throughout the years.

What can you do about it?  Under federal law (Affordable Care Act), you have the right to request a medically necessary exception when a formulary change puts your care at risk.  Federal Law: 45 CFR § 156.122(c) “A health plan providing essential health benefits must have a process in place that allows an enrollee, their designee, or prescribing provider to request access to a clinically appropriate drug not otherwise covered by the plan. If granted, the plan must treat the excepted drug as an essential benefit and must respond within 72 hours.”

In the appeal process example below, Zepbound is specifically addressed, but please note that the process would be the same if appealing for an exception of OneTouch test strips or any other drug removed from the formulary list.

Starting July 1, your claim for Zepbound (and OneTouch) was denied. For most members, alternative GLP's are appropriate, but an appeal process is available to support members who cannot use Wegovy or Saxenda.  Your appeal will be a formulary exception request – asking CVS Caremark to cover Zepbound (or OneTouch) for you due to medical necessity. 

Below is the appeal process that may be helpful to you, in the event you decide to appeal and submit a formulary exception request.  

• You will fax your appeal letter to 1-866-443-1172 (CVS Caremark).
• You must also include a Letter of Medical Necessity from your Doctor which must be marked as URGENT in a prominent location to force a review of 72 hours.  If it is not marked urgent you are allowing CVS Caremark to have 30 days to respond.
• Address it to the right place: Make sure your letter is properly addressed to the CVS Caremark appeals department. Include any identifiers such as your Member ID and the case/reference number of the denial on the top of the letter. A proper heading might look like a business letter: with the department’s name and address, your name, plan ID, etc. This ensures it gets routed correctly.  Keep the fax confirmation for your records.    
• State your request and reason upfront: In the opening paragraph, clearly state that you are appealing the denial of Zepbound coverage. Reference the denial reason briefly. For example: “I am writing to appeal the decision to deny coverage of my Zepbound (tirzepatide) prescription on the grounds that it is not on the formulary (CVS Caremark requiring switch to Wegovy). I am requesting a formulary exception to continue Zepbound, as it is medically necessary for me.” By doing this, the reviewer immediately knows what you want and why. Use the terminology from the denial – if they said “non-formulary” or “therapeutic interchange,” mention that and assert that you are seeking an exception.

For most members 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 (or OneTouch) despite it not being normally covered. But double-check all the 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.

The link below is a really good resource with valuable information and pointers that could help with your appeal – READ IT 

https://www.findhonestcare.com/blog-posts/how-to-appeal-a-cvs-caremark-zepbound-coverage-denial?utm_medium=seo&utm_source=hcblog

CWA Local 1103 is providing this guide to help our members with appeals requesting a medically necessary exception due to this formulary change.  However, we are not guaranteeing your appeal will be successful.  All members should be truthful when sharing information, including documentation with CVS Caremark. 

In unity,

Kevin Sheil, President, CWA Local 1103