Zepbound Coverage on CMS State of Illinois Employee Plan
This post is specifically for those who have the state of Illinois employee health plans through CMS and have Caremark as their PBM.
I have been on Zepbound for several months and used the Virta program through Health Alliance. That plan ended on 6/30 and my new BCBS IL OAP plan with Caremark began yesterday.
I wanted to make a place to discuss how it is going working on getting your Zepbound covered. It DOES appear to still be included on the State of Illinois specific formulary, but I am having a lot of trouble getting set up with their lifestyle management program Health Optimizer. I have been told even my very first prior auth will be denied if I am not enrolled in the LMP.
So far I have done the following.
- I checked the U of I specific formulary and yes the medication is on there as covered for weight loss.
- Then I did the drug pricer and it shows as 1,056.43 a month or 47000for 3 months.... not 4700 which is still over 3x... but 47000?????? There is also a note that says "prior authorization needed" so maybe once I get the prior auth it'll show the real price.
- Yesterday 7/1 I attempted to enroll in the LMP. It wanted an enrollment code but I don't have one so I entered my info stating i ddin't have a code. It wouldn't let me because it said there was no plan associated with my info.
- Next I called cms caremark asking for a code. They told me that they can't enroll me in the LMP because they don't have all of the new subscriber information processed in the system yet and to call back in a week. (even though the plan started yesterday).
- I can't wait a week because i need this enrollment to go through so I can get my medication, so I tried again today and it did recognize my info and let me enroll.
- Once going through the initial information, It prompted me to schedule a consult (like virta did) but there were zero appointments available. It gave me a number to call but that number took me to tech support which just told me to send them a message in the app requesting an appointment. Even the tech support person told me that zepbound is no longer covered. I explained it is an illinois law to cover these medciations for the CMS plans and that it IS listed on our formulary. She said well just know Health Optimizer won't chase you down to complete this. It is a lengthy process to get approved... yes I know that is why I started trying to go through this process the day the plan went into affect.
- So now I'm just in a holding pattern to set up this LMP and have been told my prescription will be denied until I'm enrolled... kind of a catch 22 and seems to violate that law.
Has anyone else with one of these CMS State of Illinois plans had any success or received any information? Hopefully this thread can be a good place to discuss the process and what is working for each of us.
Posted Jul 2, 2025, 3:22 PM UTC