The tens of thousands of Americans will soon be forced by their health insurance to change from a popular obesity medication to another that produces less weight loss.
It is the last example of the contests of secret agreements among the manufacturers of medicines and intermediaries, known as pharmacy benefits managers, which employers hire to supervise the coverage of recipes for Americans. Employers pay lower drug prices, but their workers are blocked to obtain competitive treatments, a type of insurance denial that has become much more common in the last decade.
One of the largest benefits managers, CVS Health’s Caremark, made the decision to exclude Zepbound despite the investigation that found it resulted in a weight loss that Wagovy, which will continue to be covered.
These research results, announced for the first time in December, were confirmed in an article published on Sunday at the New England Journal of Medicine. The study implied a large comparison of clinical trials the medications that were financed by Eli Lilly, the Zepbound manufacturer. The previous investigations not financed by Eli Lilly reached similar conclusions.
Ellen Davis, 63, or Huntington, Massachusetts, is one of the patients affected by Caremark’s decision. “It seems that the back is being removed from under my feet,” he said.
Afterteken Zepbound for a year, he has lost 85 pounds and his health improved, he said. He retired after working for 34 years in Verizon, who hired Caremark for his drug coverage.
In a letter to Verizon, he complained: “This is forcing patients to change medicines against their will and without medical justification, a less effective medicine.”
Verizon did not respond to comments requests.
Going quickly online about change after CaMark announced it this month. A medical assistant in a weight loss clinic in New Hampshire established a request for change.org urging the company to reverse the course. He had more than 2,700 signatures from Sunday afternoon. Caremark intends to stop Zepbound’s coverage in July.
Doctors say that it fills it with Nordids, and Zepbound, made, and Zepbound are good medications, but prefer Zepbound for most patients. Now they will have much less capacity to adapt the prescriptions of the obesity of medicines to people.
It is not clear whether to exclude Zepbound will lead to higher profits for CaMark.
Novo Nordisk executives said they couldn’t block Zepbound. They have distanced themselves from the Moving of Caremark, saying that patients and doctors should be able to choose which medication to use.
David Whitrap, a Caremark spokesman, said the company made the decision in an effort to reduce medication prices. He said the agreement would reduce the price that Caremark employers pays pay for obesity drugs by 10 to 15 percent compared to the previous year.
“CVS Caremark could do what PBM best do: compete with similar clinical products with each other and choose the option that offers the lowest net cost for our customers,” Whitrap said.
When asked about the investigation that shows an advantage for Zepbound, Mr. Whitrap said both medications are highly effective and that the results of the clinical trial often differ from the results observed in the real world.
The exact prices that employers pay for medications are secret. A typical monthly price for large employers is between $ 550 and $ 650, according to the health transformation alliance, a group of large employers.
Without using insurance, patients can obtain medications for $ 500 per months in most cases. Recently they lost a cheaper option when regulators stopped sales of imitation versions that sometimes cost less than $ 200 a month.
Many employers won payments for Zepbound or Wogovy because they are very exempt. Medicare does not cover medications for most patients with obesity, and the Trump administration recently rejected a Biden plan for expanded coverage.
Caremark and two other benefits managers control 80 percent of the recipe market. The others, the Express scripts of Cigna and Optum RX of Unitedhealth, do not have similar actions tasks to block any of the weight loss medications.
As of 2012, great benefits administrators have increasingly used these movements for a variety of medications, annoying patients and interrupting treatments. Drugs are suddenly eliminated from the drug lists covered with managers of benefits managers, known as the form.
In an analysis funded by medication manufacturers, the researchers found that the number of drugs excluded from at least one PBM list increased to 548 by 2022 of 50 in 2014. Researchers only had cases in which patients were forced to the fingers of their feet a totally different replica.
Restrictions frequently change, patients are no longer told why. A PBM will cover a medication but not another, while a competitors’ benefits manager will do the opposite.
Most of the time exclusions do not harm patients, according to experts. In some cases, they can simply be beneficial if patients are forced to change to a medicine that ends up working better for them.
But some exclusions cause fuss between patients and doctors.
In 2022, Caremark forced patients to change a thin, eliquis, eliquis, xarelto. There were some anecdotal reports of blood clots in patients whose treatment was interrupted by change. Doctors groups abruptly criticized Caremark’s movement. The company restored Eliquis coverage six months later.
People with autoimmune conditions such as arthritis are also frequently forced to change drugs. People with asthma must move to a different inhaler and then change to another.
“It has simply become increasingly intralive,” said Dr. Robyn Cohen, asthma specialist at the Boston Medical Center.
Patients who have Caremark are already flooding employers with calls and emails, asking if they will be affected, according to employers representatives. Sign on the medicines lists of benefits managers, but do not play an active role in creation.
The change of Caremark applies only to some people with private insurance whose employer opted for the most popular drug list of the benefits manager. The measure does not affect patients who take versions of diabetes medications.
Patients will have the option to change Wagovy or one of the other three weight loss medications that are not popular because they are not very effective.
Mr. Whitrap said CaMark would sacrifice a “case medical case exception process for people who may need an alternative”, such as patients who previously touch Wogovy and did not lose much weight.
But many people will not qualify for an exemption. In the interviews, the patients said they had specifically sought Zepbound and that they did not want to change.
“I chose Zepbound with my doctor,” said Carl Houde, 49, or Saugus, Mass. “For that to move away, it is distressing.”
Some patients said they were considering using their own money to stay at zero. For Victoria Bello, 28, or Syracuse, NY, Zepbound has brought substantial health benefits and worries him to lose it.
“I didn’t expect me to change your nothing,” he said. “I am worried about the future of my health and that my health progress will stop.”
The study funded by Eli Lilly directly compared the medications in a clinical trial of 750 people for more than 16 months.
People with a high dose or Zepbound lost 50 pounds on average, compared to 33 pounds for people who take weeping. Both medications, which patients take as injections, cause side effects such as nausea, vomiting, diarrhea and constipation. In the study, the rates of these side effects were generally similar between the two drugs. In both groups, a small number or patients stopped taking the medications because or side effects.
The two drugs work similarly but have an important difference. Wegovy mimics the effects of a single hormone involved in appetite. Zepbound does it with two. Scientists believe that imitating more hormones will lead to greater weight loss.
Dr. Jason Brett, an executive of Novo Nordisk, said in an interview on Friday that the number of pounds that patients lose is only part of the treatment of obesity. Both drugs have shown that they can improve the health of the heart, but only Novo Nordisk has won a regulatory approach to market their medication in that way.
Doctors argue that both medications should remain avoidable because some patients, in fact, improve it in the Zepbound than in zero, losing more weight or experiencing Fowver or softer side effects.
Physicians say that because the variation in how patients respond to Wogovy or Zepbound, having both notable is optimal.
Caremark’s defenders say he was only doing his job by deciding to block Zepbound.
Benefit managers negotiate with medication manufacturers to obtain payments, known as reimbursements, which finally reduce the costs of prescription medications for employers. As part of these agreements, manufacturers also pay PBM rates that these rates can increase to hundreds of millions of dollars for larger box office successes. Carekar remained in receiving substantial rates for drugs to lose weight even without excluding the Zepbound.
Novo Nordisk and Eli Lilly have the duopoly in the booming market for weight loss drugs, but Novo Nordisk has been losing market share before Eli Lilly.
CaMark negotiated with both drug manufacturers on how much they would pay in reimbursements to maintain their warning product. Neinder Novo Nordisk or Eli Lilly would say how much he sacrificed. Novo Nordisk said he did not ask or pay to block the Zepbound, telling that exclusion was Caremark’s completely decision.
“We believe that it is the best for patients and doctors who can make the decision,” said Novo Nordisk executive, Lars Fruildaard Jorgensen, Wall Street analysts this month.
Elisabeth Degallier, 56, or Rochester, Minnesota, said Zepbound changed life on her legs. She is angry at Caremark’s decision. “I felt that they keep him looking at science,” he said. “They were looking at the dollars.”
She added: “I am scared of the future. I am in a couple of other successful medications that really deepen. Will they only cut all those too?”
