As of today, Zepbound is back on CVS Caremark's standard formulary. Before anyone celebrates, let's read what 'standard' actually means. This is GLP-1 Daily. Today, a PBM reversal, Massachusetts getting called out for cutting coverage, a Medicaid study on what prior auth really does, and Lilly's pill in The Lancet. Plus California's plan to get into the GLP-1 business. If the show's useful, follow us wherever you're listening. CVS first.
SkinnyVIP, a telehealth company that sells compounded tirzepatide, in a coverage guide:
On May 28, 2026, CVS Health announced that Zepbound (tirzepatide) would return to CVS Caremark’s standard commercial formulary templates as an additional preferred option effective October 1, 2026. Wegovy (semaglutide) keeps its preferred status. Starting October 1, both drugs sit on the same formulary tier with the same copay for plans that follow the standard template.
That reverses the July 2025 change that made Wegovy the single preferred weight-loss GLP-1 on that template. And CVS told The Boston Globe the template covers roughly twenty-five to thirty million Americans. And yes, consider the source. This guide comes from a company selling the cash-pay alternative. But it tracks CVS's own May announcement, and it's blunt about the catch: plan sponsors keep the discretion to customize coverage. Which is the whole story. Your employer can still exclude weight-loss GLP-1s entirely, or keep Wegovy as the only preferred option. Same template, very different realities depending on who signs your paycheck. And that twenty-five-dollar copay headline? That's Lilly's manufacturer program, commercial insurance only. Medicare and Medicaid patients are generally excluded. One more practical note. If you were switched from Zepbound to Wegovy last year, the guide says your old prior auth doesn't carry back automatically. On Tuesday we covered the bipartisan backlash against PBMs. This is what a PBM retreat looks like: an option, not a mandate. If you're thinking about switching, talk to your prescriber first, then get your plan's answer in writing before open enrollment closes.
Alison Kuznitz, writing in The Boston Globe:
MassHealth dropped GLP-1 weight loss drug coverage in the fiscal 2027 budget, as the Healey administration eyed ways to trim spiraling coverage costs related to the drugs. In a divided vote in February, the Group Insurance Commission board also approved nixing GLP-1 weight loss coverage, even as some state health plan overseers said the move would exacerbate health disparities and trigger sharper costs in the long term should enrollees’ chronic conditions worsen.
On Wednesday at the State House, Martin Luther King the Third quoted his father: of all the forms of inequality, injustice in health is the most shocking. And he named the result. Two standards of care, one for people who can pay out of pocket, another for people relying on public coverage. The budget pressure is real. The Group Insurance Commission covers more than four hundred sixty thousand public employees and retirees, and it got a three-hundred-million-dollar emergency infusion this year, partly driven by GLP-1 costs. But Representative Marjorie Decker's point lands. They went from full coverage to nothing. She called it 'a panicked reaction.' She floated higher copays, or eligibility based on obesity plus comorbidities. Anything in between. And the state's own Health Policy Commission says GLP-1 spending would decrease significantly if plans paid federally negotiated or international reference prices. So the cheaper number exists on paper. Patients just aren't the ones getting it. State Health and Human Services Secretary Kiame Mahaniah said in March coverage could come back in a few years, once prices crash. Novo says Wegovy and Ozempic list prices drop to six seventy-five on January first. That's a step. It's not a crash.
Ashley Gallagher, writing in Drug Topics:
Nine states that began covering obesity-labeled glucagon-like peptide-1 receptor agonists (GLP-1 RAs) through Medicaid between 2021 and 2024 saw a significant increase in prescriptions for those products, but total GLP-1 RA use across both the obesity and diabetes indications grew by less than that increase alone, according to a study published September 25 in JAMA Health Forum.
Peer-reviewed, University of Pennsylvania researchers, Medicaid drug data from nine covering states against thirty-six that didn't cover. And guess who's on the strict prior-auth list? Massachusetts. Here's the finding. Obesity coverage added about six and a half prescriptions per thousand beneficiaries. Total GLP-1 use rose only about four, and that total wasn't statistically significant. In states with prior auth stricter than the FDA label, diabetes-labeled prescriptions grew more slowly, about three per thousand. The authors read that as substitution. Some obesity scripts are going to people who'd otherwise be on the diabetes version. Which means part of the scary new obesity spending is spending the state was already making. Tighten the rules on one label and the cost slides over to the other one. Caveat before this lands in anyone's budget memo. It's a state-level design, and the authors say it can't confirm individual patients switching. The Drug Topics write-up doesn't name a funding source, either. Fair. But their recommendation is the right one: look at cost across the whole GLP-1 class, not the obesity label in isolation. That's exactly the math a state skips when it goes from coverage to nothing.
The European Association for the Study of Diabetes, in a release on EurekAlert!:
New research to be presented at the Annual Meeting of The European Association for the Study of Diabetes (EASD) in Milan, Italy (Sept 28 – Oct 2) and published in The Lancet shows that, for people living with type 2 diabetes at increased cardiovascular risk, the new daily orforglipron pill had comparable cardiovascular safety to insulin glargine daily injections while providing superior improvements in weight reductions and blood sugar control. However, the rate of gastrointestinal (GI) adverse events was higher for orforglipron daily pills than for daily insulin glargine injections, which led to more discontinuation of orforglipron compared to insulin glargine. The study is sponsored by Eli Lilly, the manufacturer of orforglipron.
Yesterday we called Lilly's Foundayo comparisons indirect. This one's different. It's a randomized trial against insulin glargine, published in The Lancet. And sponsored by Lilly, which belongs in the first sentence, not the footnote. The main result: risk of major cardiac events sixteen percent lower than glargine, which cleared the non-inferiority bar. Translation, not worse for the heart. Lilly's release also leads with fifty-three percent lower cardiovascular death and fifty-seven percent lower death from any cause. Those are pre-planned analyses that Lilly's own table says weren't controlled for type one error. Hypothesis, not proof. The firmer numbers are weight and blood sugar. At fifty-two weeks, weight down eight point eight percent on Foundayo versus up one point seven on glargine, and A1C down one point six versus one point oh. And more people quit because of the stomach side effects. CVS already lifted its new-drug block on Foundayo back in June. Now a plan has heart-safety data to cite. Whether that reaches somebody without a diabetes code on their chart is another fight. If you have type 2 diabetes with heart risk and you've wondered about a pill, this is a good paper to bring to your prescriber.
Ernesto Centeno Araujo, for the USA TODAY Network:
Gov. Gavin Newsom signed SB 1089, the Preventive Treatment Health Care Act, into law on Sept. 28. The law authorizes California to pursue partnerships to increase competition, lower prices and address potential shortages for at least one FDA-approved GLP-1 medication used to treat obesity.
Signed Monday, under CalRx, the same program that put low-cost insulin glargine in front of Californians regardless of insurance status. If it ever produces a GLP-1, the current model suggests it'd be open to people with employer plans, Medicare, Medi-Cal, or no insurance at all. 'If' is doing a lot of work there. The law doesn't require California to make any specific drug. It authorizes partnerships. No product, no price, and no eligibility rules yet. Sure. But put it next to Massachusetts. One state walked away from coverage over price. Another just gave itself a tool to go after the price. Both of those are choices. And even then, you'd still need a prescription and have to meet the drug's medical criteria. I'll get interested when CalRx names a partner.
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The EASD meeting in Milan wraps up October 2, so we're watching for any last GLP-1 datasets.
Links to every story are in the show notes, so dig into whichever ones caught your attention. That's GLP-1 Daily for today. We'll be back tomorrow. This is a Lantern Podcast.