Tens of thousands of Americans will soon be forced by their heath insurance to switch from one popular obesity medicine to another that produces less weight loss.
It is the newest example of the consequences of secret deals between drug makers and intermediaries, known as Pharmacy benefits managersThey are hired by employers to supervise the coverage for prescription for Americans. Employers pay lower drug prices, but their employees are blocked to get competitive treatments, a kind of insurance refusal that occurs much more often in the past decade.
One of the biggest benefit managers, the Caremark of CVS Health, has made the decision to exclude Zepbound despite research that has shown that it resulted in more weight loss than Wegovy, which will be covered.
Those research results, first announced in Decemberwere confirmed in one Article published on Sunday In the New England Journal of Medicine. The study included a large clinical study in which the medicines were compared that were funded by Eli Lilly, the maker of Zepbound. Earlier Research not financed by Eli Lilly Come similar conclusions.
Ellen Davis, 63, Van Huntington, Mass., Is one of the patients affected by the decision of Caremark. “It feels like the rug is being pulled under my feet,” she said.
After she had taken Zepbound for a year, she lost 85 pounds and her health has improved, she said. She retired after working for 34 years at Verizon, who hired Caremark for her coverage.
In a letter to Verizon, she complained: “This forces patients to switch medicines against their will, and without medical justification, to a less effective medication.”
Verizon did not respond to requests for comments.
Word quickly spreads online about the change after Caremark had announced it this month. A doctor’s assistant at a weight loss clinic in New Hampshire has one Change.org Petition Encourage the company to reverse the course. It had more than 2,700 signatures from Sunday afternoon. Caremark plans to stop the coverage for Zepbound in July.
Doctors say that Wegovy, made by Novo Nordisk, and Zepbound are both good medicines, but that they prefer Zepbound for most patients. Now they will have much less power to adjust obesity medicine recipes to individuals.
It is not clear whether the exclusion of Zepbound will lead to a higher profit for Caremark.
Managers of Novo Nordisk said they were not trying to block Zepbound. They have renounced the movement of Caremark and say that patients and doctors should be able to choose which medicine they should use.
David Whitrap, a spokesperson for Caremark, said that the company made the decision in an attempt to lower the drug prices. He said that the deal would lower the price that Caremark’s employers’ customers would pay for obesity medicines by 10 to 15 percent compared to the previous year.
“CVS Caremark was able to do what PPE do best: compete clinically comparable products against each other and choose the option that delivers the lowest net costs for our customers,” said Mr. Whitrap.
When asked about the research that shows an advantage for Zepbound, Mr Whitrap said that both medicines are very effective and that the results of clinical tests often differ from the results that are seen in the real world.
The exact prices that employers pay for the medicines 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 in most cases receive the medicines for $ 500 per month. They recently have one Cheaper option When supervisors Staled sales From copycat versions that sometimes cost less than $ 200 per month.
Many employers will not pay for Zepbound or Wegovy because they are so expensive. Medicare does not cover the medicines for most patients with obesity and the Trump administration recently A BIDEN -Plan rejected For extensive coverage.
Caremark and two other benefit managers have mastered 80 percent of the recipe market. The others, Cignnas Express Scripts and Optum RX from UnitedHealth have not taken any similar actions to block one of the weight loss medicines.
From 2012, the major income managers have increasingly used these movements for a series of medicines that make patients upset and disrupt treatments. Medicines are suddenly falling from the periodically updated lists of the benefit managers of covered medicines, known as a formulary.
In one Analysis funded by drug makersResearchers discovered that the number of medicines that were excluded from at least one PPE list increased in 2022 in 2022 of 50 in 2014. The researchers only counted cases in which patients were forced to use a completely different medicine, not only moved to a generic version or other replica.
The limitations often change and patients are not told why. One PPE will cover one medicine, but not the other, while a competitive income manager will do that Do the opposite.
According to experts, the usually no damage to patients does not damage. In some cases they can even be favorable if patients are forced to switch to a medicine that works better for them.
But some exclusions call wrapping in patients and doctors.
In 2022, Caremark forced patients to switch from one frequently used blood thinner, Eliquis, to Xarelto. There were Some anecdotal reports Of blood clots in patients whose treatment was interrupted by the change. Doctor’s groups Sharp criticized Caremark‘s Move. The company restored the coverage of Eliquis six months later.
People with car -immune disorders such as arthritis are also often forced to change medicines. People with asthma have to go to another inhaler and then switch to another.
“It has just become more and more intrusive,” said Dr. Robyn Cohen, an asthma specialist at Boston Medical Center.
Patients who have caremark floods employers with phone calls and e -mails and ask if they will be affected, according to representatives of employers. They sign the lists of the benefit managers of medicines, but do not play an active role in making them.
The change of Caremark only applies to some people with a private insurance whose employer has opted for the most popular list of medicines from the Benefit Manager. The move has no influence on patients who take versions of diabetes drugs.
Patients have the opportunity to switch to Wegovy or one of the other three weight loss medicines that are not popular because they are not very effective.
Mr Whitrap said that Caremark would offer a case of a medical exceptional process for people who may need an alternative, “such as patients who previously took Wegovy and do not lose much weight.
But many people will not be eligible for an exemption. In interviews, patients said they had specifically searched Zepbound and did not want to switch.
“I chose Zepbound with my doctor,” said Carl Houde, 49, from Saugus, Mass. “To be removed, it is painful.”
Some patients said they are considering using their own money to stay on Zepbound. For Victoria Bello, 28, from Syracuse, NY, Zepbound has brought substantial health benefits and is concerned about losing them.
“I didn’t expect it to change from nowhere,” she said. “I am worried about the future of my health and that my health progress will block.”
The study funded by Eli Lilly compared the medicines directly in a clinical test with 750 people for more than 16 months.
People with a high dose of Zepbound lost on average 50 pounds, compared to 33 pounds for people who take Wegovy. Both drugs, which patients regard as injections, cause side effects such as nausea, vomiting, diarrhea and constipation. In the study, the speeds of those side effects were generally comparable between the two medicines. In both groups, a small number of patients stopped taking the medicines due to side effects.
The two medicines work in a similar way, but have an important difference. Wegovy mimics the effects of just one hormone involved in appetite. Zepbound does this with two. Scientists believe that imitation of more hormones will lead to more weight loss.
Dr. Jason Brett, a director 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 medicines have shown that they can improve the health of the heart, but only Novo Nordisk has won the approval of the regulations to market the medicine in this way.
Doctors claim that both medicines must remain available because some patients actually do better on Wegovy than on Zepbound, lose more weight or experience less or milder side effects.
Doctors say that because of the variation in how patients react on Wegovy or Zepbound, both are optimal available.
The defenders of Caremark say it just did his job to block Zepbound.
Benefit managers negotiate with drug manufacturers to get payments, known as discounts, which ultimately reduce the costs for medicines for employees. As part of these deals, manufacturers also pay costs to PBMS that can cost costs up to hundreds of million dollars for the largest blockbusters. Caremark was to receive considerable costs for weight loss medicines, even without excluding Zepbound.
Novo Nordisk and Eli Lilly have a duop oil in the flowering market for weight loss medicines, but Novo Nordisk has lost the market share to Eli Lilly.
Caremark negotiated with both drug makers about how much they would pay in discounts to keep their product available. Noro Nordisk nor Eli Lilly would say how much it offered. Novo Nordisk said it did not ask or paid to block Zepbound, and claimed that the exclusion was complete the decision of Caremark.
“We believe that it is in the best interest of patients and doctors that they can make the choice”, Novo Nordisk’s Chief Executive, Lars Fruergaard Jorgensen, told Wall Street analysts this month.
Elisabeth Degallier, 56, Van Rochester, Minn., Said that Zepbound had been life -changing. She is angry about Caremark’s decision. “I felt that they didn’t look at science,” she said. “They looked at the dollars.”
She added: “It scares me for the future. I have a few other expensive medicines that I really depend on. Are they just going to cut them?”
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