If you’re one of the many patients impacted by the forced switch from Zepbound to Wegovy, you’ve probably received a confusing series of letters and messages – some from CVS Caremark, some from your doctor, and maybe even some from your pharmacy. Understanding what each document means is key to getting back on the path to coverage.
This article breaks down the three critical documents you’ve likely received through the process. We’ll show you what they are, what they mean, and – most importantly – how to use them to get covered again.
👉 If you haven’t already, check out our full guide to fighting the Zepbound switch here.
Document 1: The Formulary Change Notice Letter
What it is:
A notification of an upcoming change to your coverage. This letter tells you that soon, a change to formulary or drug policy will remove Zepbound and prefer Wegovy. It lays out steps to prepare, such as when to file a new prior authorization (for most people, after July 1st) and how to switch your prescription.
Why you get it:
Health insurers and pharmacy benefit managers, like CVS Caremark, must provide 60 days’ advance notice to plan participants before any mid-year formulary change that removes a drug from coverage or limits its availability (e.g. adds step therapy, prior authorization, or tiering).
How to read it:
The truth? There’s not a lot in here. These letters often use vague language like “no longer be covered” and “you’ll need to pay the full cost”, but don’t provide specifics. That’s because, importantly, this is not a denial, which is required to provide you much more detail.
Key takeaway:
This letter alone does not mean that your Zepbound prescription has been denied, or trigger your right to appeal. It’s a heads-up, not a final decision.
Document 2: Your Doctor’s New Prior Authorization Form
What it is:
A prior authorization is a form your doctor submits ahead of prescribing something, so the insurer can sign off on your treatment before it gets prescribed. With the Caremark switch, even if you had a prior authorization (PA) approved for Zepbound, your doctor must submit a new one after July 1. This is the PA form they must submit, and we also recommend they draft a letter of medical necessity.
Why it’s necessary:
Because Caremark’s formulary changed, all existing PA approvals under the old formulary are essentially wiped out. Your provider needs to justify, again, that the treatment is medically necessary and follows standard guidelines. If this feels like a huge waste of time, providers agree: PA has been proven to delay care and harm patients, and it’s costly for providers to complete.
How to use it:
Ask your doctor if a new PA has been submitted. This is your official request for your insurance to cover Zepbound, and it needs to be on record after July 1 for the appeals process to work. For best results, have them include a letter of medical necessity (you’ll also want this ready for your appeal). A little appreciation goes a long way.
Key takeaway:
An official denial won’t come until a new PA is submitted. This form restarts the process.
Document 3: The Denial Letter (Now You Can Appeal)
What it is:
This is the official decision from your insurer rejecting the PA request for Zepbound. It typically arrives by mail or through your health plan portal.
Why you get it:
Insurers and PBMs (like CVS Caremark) are legally required to ensure you understand the reason for a coverage denial and have a meaningful opportunity to appeal. When denial language is vague, incomplete, or misleading, it undermines this legal purpose and obstructs fair access to care – and if that happens, we can help you fight it.
How to read it:
Look for the specific denial rationale and appeal instructions. You might see language like “the primary covered drug for your plan is Wegovy” or “another option for you is a tirzepatide product.”
This language is misleading: You always have the right to request a formulary exception when no equivalent alternative exists. Zepbound is the only FDA-approved tirzepatide for obesity and sleep apnea, and has also been proven to be more effective, with fewer side effects, than Wegovy. Thus, it is the only tirzepatide product that should be covered by your plan.
What we think? This gives you a strong case to stay on Zepbound in your appeal.
Key takeaway:
This denial is what makes you eligible to file an appeal. If you haven’t gotten this yet, first make sure the PA has been submitted. If you appeal before you get this denial, it may be rejected or ignored – but don’t worry if this happens. You can resubmit.
Putting It All Together
A successful Zepbound appeal means getting the documents right:
1. The 60-day notice tells you this is coming, but isn’t a denial.
2. Your doctor’s new PA starts the process under the new rules.
3. Your denial letter gives you the right to appeal.
👉 If you’ve received your denial letter and are ready to appeal, Claimable can help you fight back in minutes. Get started today.
Need Help?
Still confused? You’re not alone. These documents weren’t designed for patients. That’s why Claimable exists – to help you translate legal jargon into action. Reach out at support@getclaimable.com.
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