Pharmacy benefit manager CVS Caremark decided to replace Zepbound with Wegovy for use in weight loss starting July 1, despite Zepbound users having more weight loss success.
The company will no longer cover Zepbound, which is made by Eli Lilly, which was approved in November 2023 by the Food and Drug Administration for weight management in adults who are obese or are overweight, CNN reported.
CVS Caremark alerted customers who used Zepbound in May, writing them in a letter, “This change is happening because there’s another covered medication that’s safe and effective for your condition and may cost less.”
Pharmacy benefit managers (PBMs) negotiate for discounts and rebates with drugmakers for preference in what is covered, Forbes explained. PBMs also process pharmacy claims. The largest are CVS Caremark; Express Scripts, which is Cigna’s PBM; and OptiumRx, which is UnitedHealth. The three companies control about 80% of the market.
Wegovy will now be the GLP-1 weight loss drug of choice under plans that are managed by CVS Caremark.
If they stay on Zepbound for their GLP-1 weight loss treatment, they will have to pay full price, the company warned.
They can also file an exception that may allow them to keep Zepbound as their covered treatment, CNN reported.
If they have to pay full price, Eli Lilly has expanded its LillyDirect program, but a single dose of Zepbound will cost $499 a month, CNN reported.
The list price of the drugs can be more than $1,000 a month, Forbes reported in May when the news first broke.
Novo Nordisk said at the time that it did not ask for its competition to be blocked by CVS Caremark, The New York Times reported.
CVS Caremark said in May that the move will save its employer clients 10 to 15% when compared to the previous year, the newspaper reported.
Some employers won’t pay for either treatment because of the high cost.
CVS claims the move will have Eli Lily and its competitor Novo Nordisk, which makes Wegovy, to compete and lower prices for their treatments.
“The egregiously high list prices set by drug manufacturers of GLP-1s for weight loss are the single biggest barrier to patient access,” CVS Health said in a statement, according to CNN. “Our formulary strategy maintains clinically appropriate coverage while using competition to drive lower costs.”
Prior to the change, the company said that users of each medication were basically equal.
But doctors and patients claim that while the two medications are both GLP-1, they work differently, and that science supports them.
Two studies — one backed by Zepbound’s parent company and one that was not — both showed that Zepbound resulted in more weight loss when compared to Wegovy, The New York Times reported in May.
Endocrinologist Dr. Jody Dushay said that treatments take time and trial and error to find a plan that works. Sometimes it is the side effects of the treatment or an allergic reaction that guides the choice between different medications.
“Largely across society, we don’t accept obesity as a long-term chronic disease, and we’re still looking for quick fixes and quick solutions where that’s not the reality of the biology and disease process. The mindsets have not caught up with the science yet,” Dr. Tracy Zvenyach, from the nonprofit Obesity Action Coalition.
“If decision-makers do not understand obesity to be a long-term chronic disease, that’s when we see these exclusionary policies or these very, very cumbersome utilization management practices that really just set up one barrier after another to prevent people from getting the care that they need. It’s unacceptable. We don’t do that with other chronic diseases.”
A different change is on the horizon for patients who are covered by BCBS Massachusetts. All GLP-1s will be removed for weight loss and will only be covered for the treatment of type 2 diabetes, CNN reported.
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