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<\/p>\n Email Link<\/p>\n \n A class-action lawsuit has been filed against CVS Caremark over its decision to stop covering Zepbound, Eli Lilly\u2019s blockbuster GLP-1 drug to treat obesity.\n <\/p>\n \n When the major pharmacy benefit manager informed patients about the change this year<\/a>, it suggested that there was \u201canother covered medication that\u2019s safe and effective for your condition and may cost less\u201d: namely Wegovy, from Novo Nordisk, with which CVS Caremark announced a partnership<\/a> just before the change took effect.\n <\/p>\n \n But many patients and their doctors say the treatments aren\u2019t medically interchangeable.\n <\/p>\n \n John Cole, who lives in the Midwest, says he lost more than 60 pounds over the course of about five months while using Zepbound. Letters from his family medicine doctor, cardiologist and rheumatologist all indicate that he\u2019s benefited from this treatment. But he\u2019s gained some weight back after losing access to Zepbound through CVS Caremark, and his care team has submitted dozens of letters to the company over the past two months amid repeated appeal denials.\n <\/p>\n \n \u201cIt is my professional opinion that the patient\u2019s health problems all seem to be improving on Zepbound and we would be hesitant to switch medications when things are going well,\u201d one of Cole\u2019s doctors wrote to CVS Caremark.\n <\/p>\n \n Zepbound and Wegovy are both effective at treating obesity and approved by the US Food and Drug Administration to do so, but there are differences.\n <\/p>\n \n Studies have found<\/a> that people who used tirzepatide injections such as Zepbound lost more weight and were more likely to reach specific weight loss targets than those using semaglutide medications such as Wegovy. The two drugs have a different set of broader indications, with Zepbound also approved to treat sleep apnea<\/a> in people with obesity, for example. Side effects can vary too, sometimes making one medication more tolerable than the another.\n <\/p>\n \n The lawsuit, filed Wednesday in the Southern District of New York, alleges that the change from CVS Caremark \u2013 and subsequent denials of patient and doctor appeals \u2013 violates standards for evaluating the medical necessity of treatment options under the Employee Retirement Income Security Act, which is applicable to employer-sponsored health plans.\n <\/p>\n \n \u201cBecause of their different methods of action, different clinical outcomes, and different side effects for individual patients, Zepbound and Wegovy are not clinically interchangeable,\u201d the complaint reads. \u201cAnd as studies have proven, Zepbound is more effective than Wegovy in achieving weight loss, and only Zepbound is has been proven effective and approved by the FDA for treating sleep apnea in patients with obesity.\u201d\n <\/p>\n \n The lawsuit seeks to restore coverage of Zepbound for people on CVS Caremark plans and award other \u201cappropriate equitable relief.\u201d\n <\/p>\n \n CVS Caremark says the suit is \u201cwithout merit.\u201d\n <\/p>\n \n \u201cWe\u2019ll defend ourselves vigorously against those claims,\u201d David Whitrap, vice president of external affairs for CVS Health, said in an email.\n <\/p>\n \n CVS maintains that Wegovy and Zepbound are \u201ctwo clinically similar products\u201d and that \u201cforcing the drug manufacturers to compete with one another on price\u201d will encourage both Eli Lilly and Novo Nordisk to lower prices for their products in the US and broaden access overall.\n <\/p>\n \n \u201cOur formulary strategy maintains clinically appropriate coverage while using competition to drive lower costs. By drawing upon our decades of expertise in making prescription drugs more affordable and accessible, we are confident that our formulary move means lower costs and better outcomes for consumers and our customers,\u201d Whitrap wrote in the email, also noting that a medical exceptions process is available for the \u201crare cases\u201d in which \u201con-formulary options prove ineffective or cause harmful side effects.\u201d\n <\/p>\n \n The coverage change made by CVS Caremark in July applies to the most common formulary template, which represents between 25 million and 30 million individuals overall.\n <\/p>\n
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