Tens of thousands of Americans will soon be forced to switch from popular obesity pills to another obesity pill that will help you lose less weight due to Heath's insurance.
This is the latest example of the outcome of a secret deal between a drug manufacturer and an intermediary known as a pharmacy benefits manager, and is employed by an employer to oversee prescription coverage for Americans. Employers pay lower drug prices, but workers are blocked from receiving competing medical care. This is a type of insurance denial that has become much more common in the past decade.
Caremark from CVS Health, one of the biggest benefits managers, decided to rule out Zepbound despite studies that have found it to lead to weight loss over Wegovy.
These findings, first published in December, were confirmed in an article published Sunday in the New England Journal of Medicine. The study included a large clinical trial comparing drugs funded by Eli Lilly, the maker of Zepbound. Previous studies that were not funded by Eli Lily have come to similar conclusions.
Ellen Davis, 63, of Huntington, Massachusetts, is one of the patients affected by Caremark's decision. “It feels like the rug is being pulled out under my feet,” she said.
After taking Zepbound for a year, she lost 85 pounds and her health improved, she said. She retired after working on Verizon for 34 years.
In a letter to Verizon, she complained, “This forces patients to switch medicines to less effective without justification for medical care.”
Verizon did not respond to requests for comment.
After Caremark announced this month, Word quickly spread the changes online. Joseph Zucchi, a physician assistant at Waitros Clinic in New Hampshire, set up a Change.org petition, urging the company to reverse the course. Last year, Zucchi announced that he would receive compensation as a speaker for Lily. As of Sunday afternoon, the petition had over 2,700 signatures.
Caremark plans to stop coverage for Zepbound in July.
Doctors say that Wegovy, made by Novo Nordisk and Zepbound, is both good drugs, but prefers Zepbound over most patients. Now they have much less ability to adjust obesity medication prescriptions to individuals.
It is not clear whether excluding Zepbound will result in better Caremark profits.
Novo Nordisk executives said they were not trying to block Zepbound. They keep their distance from Caremark's movement, saying that patients and doctors should be able to choose the medication they use.
Caremark spokesman David Whitrap said the company has made a decision to lower drug prices. He said the deal would reduce the price paid by Caremark's employer clients for obesity drugs by 10-15% compared to the previous year.
“CVS Caremark has allowed PBMS to do their best. We choose the option to compete with each other for clinically similar products and provide the lowest net cost to our clients,” Whitrap said.
When asked about studies showing the benefits of Zepbound, Whitrap said that both drugs are very effective and that results from clinical trials often differ from those seen in the real world.
The exact price that an employer pays for drugs is a secret. According to the Health Transformation Alliance, a group of large employers, the typical monthly price for a large employer is between $550 and $650.
Without insurance, patients can get their medication for most of the time for $500 a month. They recently lost cheaper options when regulators stopped selling copycat versions that cost less than $200 a month.
Many employers don't pay either Zepbound or Wegovie because they are so expensive. Medicare doesn't cover drugs for most obese patients, and the Trump administration recently rejected the Biden plan for expanding coverage.
Caremark and two other benefits managers control 80% of the prescription market. Other Cigna Express Scripts and UnitedHealth's Optum Rx have not taken similar actions to block any of the weight loss medications.
Since 2012, large benefits managers have been using these moves more and more to upset patients and disrupt treatments. The drug was suddenly dropped from the benefit manager's regular updated list of eligible drugs.
In a drug manufacturer-funded analysis, researchers found that the number of drugs excluded from at least one PBM list increased from 50 to 548 from 50 in 2014.
Limitations change frequently and patients cannot tell them why. One PBM covers one drug, but not another, but competing benefits managers do the opposite.
Exemptions say in most cases, exclusions do not harm the patient. In some cases, they can even be beneficial if patients are ultimately forced to switch to a drug that works better.
However, some exclusions cause a stir between patients and doctors.
In 2022, Caremark forced patients to switch from one widely used blood thin elixis to Xarelto. There have been several anecdotal reports of blood clots in patients whose treatment was disrupted by changes. The group of doctors has sharply criticized Caremark's move. The company recovered coverage of Elixis six months later.
People with autoimmune conditions such as arthritis are also forced to frequently exchange drugs. People with asthma should move to another inhaler and switch to another inhaler.
“We've seen a lot of different things,” said Dr. Robin Cohen, an asthma expert at Boston Medical Center.
According to employer representatives, patients with care marks have already accepted calls and emails from their employers and asked if they would be affected. They will be on the benefit manager's drug list, but they have not played an active role in creating them.
Caremark changes apply only to some private insurance people whose employers have selected the Benefits Manager's most popular drug list. This movement does not affect patients taking a version of the diabetic drug.
Patients have the option to switch to Wegovy or one of three other weight loss medications.
Whitrap said Caremark offers a “case-by-case medical exception process for individuals who may need an alternative,” including patients who have previously taken Wegovy and have not lost weight.
However, many people do not qualify for the exemption. In an interview, the patient stated that he was looking for a zepbound specifically and did not want to switch.
“I chose Zepbound with my doctor,” said Carl Hoode, 49, of Saugus, Massachusetts.
Some patients said they are considering using their money to stay at Zepbound. For 28-year-old Victoria Bello of Syracuse, New York, the Zepbound has brought about great health benefits and she is worried about losing it.
“I didn't expect it to change out of nowhere,” she said. “I'm worried about my health future and the slowdown in my health progress.”
A study funded by Eli Lilly compared drugs directly in 750 clinical trials over 16 months.
People with high doses of Zepbound lost an average of 50 pounds compared to 33 pounds for those taking Wegovy. Both drugs that patients take as injections cause side effects such as nausea, vomiting, diarrhea and constipation. In this study, the proportion of these side effects was generally similar between the two drugs. In both groups, a small number of patients stopped taking the medication due to side effects.
The two drugs work in a similar way, but with important differences. Wegovy mimics the effects of only one hormone involved in appetite. Zepbound does so in two. Scientists believe that mimicking more hormones will lead to more weight loss.
Dr. Jason Brett, a Novo Nordisk executive, said in an interview Friday that the number patients lose is just part of the treatment for obesity. Both drugs show that they can improve heart health, but only Novo Nordisk has earned regulatory approval to sell the drug in that way.
Doctors argue that both drugs need to be available, as Wegovy is actually better than Zepbound, lose weight, or experience milder side effects.
Doctors say it's best to be able to use both because of variations in how patients respond to either Wegovy or Zepbound.
Caremark's defender says he's just doing his job by deciding to block Zepbound.
Benefits managers negotiate with the pharmaceutical company to receive a payment known as a rebate that ultimately reduces the employer's prescription drug costs. As part of these transactions, manufacturers pay PBMs. These fees could be up to hundreds of millions of dollars for the biggest blockbusters. Caremark was standing to receive a substantial fee for weight loss medication without excluding Zepbound.
Novo Nordisk and Eli Lilly will double in a booming weight loss pill market, but Novo Nordisk has lost Eli Lilly's market share.
Caremark negotiated with both drugmakers on how much they would pay in rebates to make the product available. Neither Novo Nordisk nor Eli Lilly would say how much it provided. Novo Nordisk said it would not ask or pay to block Zepbound, claiming that the exclusion was a complete care mark decision.
“We believe that patients and physicians can choose is the greatest benefit of patients and physicians,” Lars Fruergaard Jorgensen, CEO of Novo Nordisk, told a Wall Street analysts this month.
Elizabeth DeGalier, 56, of Rochester, Minnesota, said Zepbound was life-changing. She gets mad at Caremark's decision. “They felt they didn't see science,” she said. “They were looking at the dollar.”
She said, “It scares me of the future. I'm really taking some other expensive medications that I really depend on. Are they going to cut it too?”
