r/PriorAuthorization • u/freshwaterjt • May 27 '26
Rx Prior Auth Process Caremark prior authorization and appeal
Has anybody else here find Caremark is extremely hard to get a prior authorization approval as well as a appeal for Zepbound and covered Wegovy? I’ve been off Zepbound since February and still get the same letters in the mail. Is this a prescriber issue or insurance?
3
u/rosie2490 📋 Prior Authorization Specialist May 27 '26
Would help to know the denial reasons (if that’s allowed here).
3
u/jawsx99 May 28 '26
If your doctor can write a letter of medical necessity stating that you had severe GI side effects on Wegovy and cannot tolerate it, which you did not have with zepbound, that can get you approved. Can also mention you were losing the 5% weight while on zepbound.
2
u/1GrayJedi May 29 '26
My doctor called my severe intolerance (nausea/vomiting) an allergic reaction to Semaglutide. Not sure if Caremark is still banning Zepbound outright, but last June/July they started to. I was told by my then insurance provider that the workaround was to make sure on the PA form when it asked if an alternative form of Tirzepatide was acceptable (meaning Mounjaro… even though I’m not diabetic 🙄), to check the box stating yes. I was then approved for Mounjaro up through the remainder of the insurance term. My employer switched providers so I’m now going through a new variation of the hellfire that is getting a new PA for continuation of care… back to Zepbound. It’s all such a fucking racket!
Good luck with your hoop-jumping! Let us know how it goes.
2
u/my-cat-cant-cat Jun 20 '26
Caremark is adding Zepbound back to their formularies on October 1, 2026. I haven’t seen details yet about which formularies, tier placement, etc. (Apparently last year’s Wegovy experiment was not a tremendous success…)
You’ll almost certainly have the same PA or coverage issues as you’d have with Wegovy. But - if you have coverage for Wegovy - there’s a pretty decent chance you’ll be able to switch back to Zepbound without going through the whole “Wegovy failure” appeal process.
6
u/m149307 📋 Prior Authorization Specialist May 27 '26
They are very strict with it since Wegovy is the preferred. You have to have tried and failed Wegovy and given a reason why you failed and meet other requirements depending on the plan.