Yes, the Empire Plan does cover Zepbound (tirzepatide) for weight management and for moderate-to-severe obstructive sleep apnea, but every prescription has to clear prior authorization through CVS Caremark first. Zepbound sits on the plan’s Advanced Flexible Formulary as a preferred anti-obesity agent, so once your doctor documents that you meet the clinical criteria, it’s filled like any other preferred brand drug at a retail or mail-order pharmacy.1NYS Department of Civil Service. Advanced Flexible Formulary Preferred Drug List
What You Have to Qualify For
CVS Caremark administers the Empire Plan’s drug benefit, and your prescriber submits the prior authorization request directly to them. The criteria depend on why Zepbound is being prescribed.
Weight Management
For weight loss or maintenance, you must have participated in a comprehensive weight management program involving behavioral modification, diet, and physical activity for at least six months before starting the drug.2CVS Caremark. Zepbound Prior Authorization Form On top of that, you need to meet a BMI threshold:
- A BMI of 30 or higher qualifies on its own.
- A BMI of 27 or higher qualifies if you also have a weight-related condition such as hypertension, type 2 diabetes, or dyslipidemia.
You also have to commit to a reduced-calorie diet and increased physical activity while taking the medication. Initial approval runs for eight months.2CVS Caremark. Zepbound Prior Authorization Form
Obstructive Sleep Apnea
For moderate-to-severe OSA, a sleep study has to show an apnea-hypopnea index of at least 15 events per hour, and your BMI must be 30 or higher. Initial approval lasts six months.2CVS Caremark. Zepbound Prior Authorization Form
Renewing After the First Approval
Continuation isn’t automatic. To get coverage renewed for weight management, you need at least three months on a stable maintenance dose and documented weight loss of at least five percent from baseline, or maintained loss of that five percent. Continuation approvals then last 12 months.3CVS Caremark. Zepbound Clinical Coverage Criteria
How Much You’ll Pay
Zepbound is a preferred brand-name drug, so it falls under the Empire Plan’s Level 2 copayment tier. The exact amount depends on your bargaining unit or group. For the 2026 plan year, one published schedule lists Level 2 copays at $30 for a 30-day supply at a retail or mail-order pharmacy and $55 to $60 for a 31-to-90-day supply.4NYS Department of Civil Service. Empire Plan Comparison – Group 6 Another group’s schedule shows $25 for a 30-day supply and $50 for a 90-day supply.5NYS Department of Civil Service. Empire Plan Copayment Schedule
Prescription drug costs under the Empire Plan don’t count toward the plan’s overall out-of-pocket maximum, and there is no separate prescription drug deductible.6NYS Department of Civil Service. Empire Plan Comparison To confirm your copay, check empireplanrxprogram.com or call 1-877-7-NYSHIP (1-877-769-7447), option 4.
One quantity limit to know: regardless of dose strength, Zepbound is capped at four pens (2 mL total) per 21 days for a one-month fill, or 12 pens (6 mL) per 63 days for a three-month fill.2CVS Caremark. Zepbound Prior Authorization Form
If You’re Denied
If CVS Caremark denies the prior authorization, your prescribing physician can submit a letter of medical necessity with supporting clinical documentation. Further appeal rights are spelled out in the denial letter you receive.7NYS Department of Civil Service. Reporting on Prescription Drugs Eli Lilly also publishes a medical appeals guide and a template letter of medical necessity on its Zepbound site that your doctor can adapt.8Eli Lilly. Zepbound Access and Coverage
A Note on the Lilly Savings Card
The Zepbound Savings Card from Eli Lilly is restricted to people with commercial insurance and excludes anyone enrolled in government-funded healthcare programs such as Medicare, Medicaid, TRICARE, and VA benefits. Because the Empire Plan is a state employee benefit, whether your coverage counts as commercial for savings-card purposes depends on how your specific plan is structured. If you qualify, the card can bring the cost down to as little as $25 per month, subject to an annual savings cap of $1,300.9Eli Lilly. Zepbound Savings Confirm eligibility at zepbound.lilly.com/savings or ask your pharmacist before counting on that price.