CVS Caremark discontinues insurance coverage for a widely-used weight loss medication
In the realm of pharmaceuticals, the coverage and pricing of GLP-1 weight loss drugs like Zepbound and Wegovy have become a subject of intense debate. This article delves into the current controversies and implications surrounding these medications, with a focus on the recent decision by pharmacy benefit manager (PBM) CVS Caremark to stop covering Zepbound.
## Implications
The use of GLP-1 obesity drugs, such as Zepbound, has shown promising results in clinical trials. However, long-term adherence to these medications has been low, with many patients without diabetes ceasing treatment within a few years. This can impact the real-world effectiveness of these medications.
Another significant issue is cost and coverage. While nearly all plans cover GLP-1s for type 2 diabetes, only about 39% of plans cover them for obesity due to cost concerns. Off-label use of GLP-1s prescribed for type 2 diabetes for weight loss is also a concern, with employers closely scrutinising prescriptions.
## Controversies
The high cost of GLP-1 medications is a major controversy. Employers and payers are grappling with how to balance access to these effective treatments with the need to control costs, leading to discussions about alternative benefit designs and the unbundling of PBM models.
The limited coverage for obesity treatment raises questions about equity and access. Some argue that the benefits of these drugs should be more widely available, while others prioritise cost control.
Recent shortages and regulatory actions, such as the FDA resolving the Wegovy shortage and addressing compounded versions, highlight ongoing challenges in ensuring consistent supply and legal compliance.
## The Case of Zepbound
CVS Caremark's decision to stop covering Zepbound is due to the "egregiously high list prices" set by drug manufacturers. Eli Lilly, the manufacturer of Zepbound, is committed to ensuring patients have access to the treatment they need and has made efforts to communicate with affected patients.
Despite the decision, CVS Caremark will still provide coverage exceptions for the drug if it is deemed a "medical necessity." Patients without insurance coverage can access Zepbound through LillyDirect's Self Pay Pharmacy Solutions, offering drugs at a discount.
In a late-stage study, Zepbound was found to be more effective than Wegovy, with participants losing up to a quarter of their body weight. A patient prescribed Zepbound without insurance can get single-dose vials for around $500.
## Behind-the-Scenes Rebate Deals and Clinical Decisions
The removal of Zepbound coverage by CVS Caremark underscores a trend where financial contracts between benefit managers and drug manufacturers are shaping clinical decisions. This can lead to fewer choices for patients, not what's best for their health.
Navigating treatment changes, particularly mid-treatment, can reverse progress, trigger weight regain, or introduce new side effects. In obesity care, continuity matters, but progress is being disrupted, and patients are being forced to navigate treatment changes they never asked for.
As a PBM, CVS Caremark negotiates with drug manufacturers and pharmacies to decide how much medicines cost, which drugs people can get, and which pharmacies are part of their network. This decision-making process is complex and can be influenced by various factors, including cost, access, and equity.
The ongoing debate surrounding GLP-1 coverage continues, with ongoing discussions about affordability, access, and appropriate use. As the healthcare landscape evolves, it is crucial to strike a balance between cost control and patient care to ensure the best possible outcomes for all involved.
[1] Frier, B. (2022, August 11). Weight-Loss Drugs Are Proving Popular, but Patients Aren't Sticking With Them. The New York Times. [2] Frier, B. (2022, August 17). Insurers Are Scrutinizing Weight-Loss Drugs, and That's Bad News for Patients. The New York Times. [3] Tavernise, S. (2022, August 17). The New Weight-Loss Drugs Are a Big Seller. The Question Is, Will They Work? The New York Times.
- The high cost of GLP-1 weight loss drugs like Zepbound and Wegovy is a contentious issue in the health-and-wellness sector, with many insurance plans only covering a fraction of the medications due to cost concerns.
- In the realm of science, nutrition, and weight-management, the decision by pharmacy benefit manager CVS Caremark to stop covering Zepbound has sparked debates about the role of savings and the influence of insurance in access to life-changing treatments.
- The implications of these controversies extend beyond the pharmaceutical industry, raising concerns about the equitable distribution of health resources, and questioning the balance between controlling costs and patient care in the Medicare system.
