Thousands of Americans will soon be transformed by their health insurance from a popular obesity drug to another drug that reduces weight loss.
This is the latest example of the consequences of a secret deal between drug manufacturers and middlemen, known as pharmacy welfare managers, who are hired by employers to monitor Americans’ prescription coverage. Employers pay lower drug prices, but their workers are unable to access competitive treatment, an insurance denial that has become increasingly common over the past decade.
CVS Health's Caremark is one of the largest welfare managers, and although research found it would result in larger weight loss than Wegovy, it still excluded Zepbound, which will continue to be covered.
The findings, first announced in December, were confirmed in a post published Sunday in the New England Journal of Medicine. The study involved a large clinical trial comparing drugs funded by Zepbough manufacturer Eli Lilly. No earlier research funded by Eli Lilly came to similar conclusions.
Ellen Davis of Huntington, Massachusetts, 63, is one of the patients affected by Caremark's decision. “It feels like the carpet is pulling out from under my feet,” she said.
She said she lost 85 pounds after taking it for a year and her health improved. She retired after working at Verizon for 34 years, and the company hired Caremark's drug coverage.
“This forces patients to switch drugs against their will, without medical evidence, and use less efficient drugs.”
Verizon did not respond to a request for comment.
Word spread rapidly online after Caremark announced this month. Joseph Zucchi, physician assistant at a weight loss clinic in New Hampshire, set up a Change.org petition urging the company to reverse courses. Last year, Mr. Spain revealed that he would receive compensation as a spokesperson for Eli Lilly. As of Sunday afternoon, the petition had more than 2,700 signatures.
Caremark intends to stop Zepbough reporting in July.
Doctors say Novo Nordisk and Zepbough’s Wegovy are good medications, but for most patients, they prefer Zepbound. Now, they will have much less ability to tailor the prescription of obesity medications to individuals.
It is not clear whether excluding Zepbound will lead to higher profits on Caremark.
Novo Nordisk executives said they did not try to stop Zepbough. They have moved away from Caremark's move, saying patients and doctors should be able to choose which medication to use.
Caremark spokesman David Whitrap said the company decided to lower the price of drugs. He said the deal would reduce the price of obesity drugs paid by Caremark’s employer clients by 10% to 15% compared to the previous year.
Mr Whitrap said: “CVS Caremark is able to do the best thing about PBM: compete with each other for clinically similar products and choose the option to offer customers the lowest net cost.”
When asked about the study showing Zepbough’s study, Mr Whitrap said both drugs are very effective and clinical trial results are often different from those found in the real world.
The exact price the employer pays for drugs is secret. A health transformation alliance for large employers says the typical monthly price for large employers is between $550 and $650.
Without insurance, in most cases, patients can get medication for $500 per month. Recently, when regulators stopped selling imitation versions that cost less than $200 a month, they lost their cheap options.
Many employers won't pay for Zepbough or Wegovy because they are so expensive. Medicare has not covered the drugs for most obese people, and the Trump administration has recently rejected Biden's expanded coverage.
Caremark and two other welfare managers jointly control 80% of the prescription market. Others, Cigna's Express scripts and UnitedHealth's Optum RX, did not take similar actions to prevent any weight loss medication.
Since 2012, huge welfare managers have increasingly used these actions to a range of medications, disturbing patients and disrupting treatments. The drug is suddenly removed from the welfare manager's regularly updated list of covered drugs, called a formula.
In a drugmaker-funded analysis, the researchers found that the number of drugs excluded from the 50 PBM list in 2014 increased to 548 in 2022. The researchers only calculated cases where patients were forced to use completely different drugs, rather than just moving to a universal version or other replica.
Limitations change frequently and the patient does not tell why. One PBM will cover one drug, but not another, while the competitive welfare manager will reverse.
Experts say that exclusion will not harm the patient in most cases. In some cases, they may even be beneficial if patients are forced to switch to medications that end up working better for them.
But some exclusions caused a commotion among patients and doctors.
In 2022, Caremark forces patients to switch from a widely used blood-thinned Eliquis to Xarelto. There are some anecdotal reports that the patient's blood clot was interrupted by changes. The doctors group severely criticized Caremark's actions. Six months later, the company resumed Eliquis' coverage.
People with autoimmune diseases, such as arthritis, are also often forced to change their medications. People with asthma must be transferred to another inhaler and switch to another inhaler.
“It's becoming more invasive,” said Dr. Robyn Cohen, an asthma specialist at Boston Medical Center.
The employer's representative said patients with Kalemac were already flooding their employers with phone and email, asking if they would be affected. They signed a list of benefits managers’ medicines, but did not play an active role in creating them.
Caremark's changes are only available to some people with private insurance, whose employers have chosen a list of the most popular medicines for welfare managers. This move will not affect patients taking diabetes medications.
Patients can choose to switch to Wegovy or one of three other weight loss medications that are not popular because they are not very effective.
Mr Whitrap said Caremark will provide “case-by-case medical abnormality” for individuals who may need alternatives, such as those who have previously taken Wegovy and have not lost weight.
But many people will not qualify for exemption. In the interview, the patient said they specifically looked for Zepbound and did not want to switch.
“I chose the doctor’s Zepbound,” said Carl Houde, 49, of Soggs, Massachusetts. “For this, it’s painful.”
Some patients say they are considering using their money to stay on the zepbound. For Victoria Bello, 28, of Syracuse, NY, Zepbough has brought considerable health benefits, and she fears losing it.
“I didn't expect it to be everywhere,” she said. “I'm worried about my healthy future and my health will stagnate.”
Eli Lilly funded study directly compared drugs in clinical trials of 750 people over 16 months.
People with high doses of Zepbound lost an average of 50 pounds, while those who took Wegovy lost 33 pounds. Patients consider both drugs as injections, which can cause side effects such as nausea, vomiting, diarrhea and constipation. In the study, the rates of side effects were usually similar between the two drugs. In both groups, a few patients stopped taking medication due to side effects.
The two drugs work in a similar way, but have important differences. Wegovy imitates appetite with only one hormone effect. Zepbound does this with both. Scientists believe that imitating more hormones can lead to more weight loss.
Dr. Jason Brett, an executive at Novo Nordisk, said in an interview Friday that the number of patients lost is only part of the treatment of obesity. Both drugs show that they can improve heart health, but only Novo Nordisk has won regulatory approval in this way.
Doctors believe that both drugs should remain available because in fact some patients perform better on Wegovy than Zepbound, with fewer or fewer weight loss or side effects.
Doctors say that the changes in how patients respond to Wegovy or Zepbound are optimal.
Caremark's defender said it was just deciding to stop Zepbough's work.
The welfare manager negotiates with the drug manufacturer to get a payment called a discount, which ultimately reduces the cost of prescription drugs by employers. As part of these deals, manufacturers also paid PBM fees that could total billions of dollars for the largest blockbusters. Caremark has a huge fee for getting weight loss pills even without excluding Zepbough.
Novo Nordisk and Eli Lilly have two important monopolies in the booming weight loss pill market, but Novo Nordisk has been losing market share to Eli Lilly.
Caremark and two drugmakers can pay how much at the discount to keep their products available. Neither Novo Nordisk nor Eli Lilly said how much it offers. Novo Nordisk said it did not ask or pay to block Zepbound, believing that exclusion was entirely Caremark's decision.
“We think it's in the best interests of patients and doctors,” Novo Nordisk CEO Lars Fruergaard Jorgensen told Wall Street analysts this month.
Elisabeth DeGallier, 56, of Rochester, Minnesota, said Zepbarton has changed his life. Karimke's decision made her angry. “I don't think they look at science,” she said. “They look at the dollar.”
She added: “It scares me about the future. I'm using several other expensive drugs that I really rely on. Are they just going to cut those drugs, too?”
