Last week, Tara Eacobacci was appointed a doctor who is dedicated solely to the topic of health insurance. A major change in the merits of her prescription meant that the medication she used to manage her weight, the treatment she had been doing the right thing over many years, was no longer covered by insurance.
“I’m totally furious,” Ecobatch said. “It’s not only causing me stress, it’s making me mad.”
Starting Tuesday, CVS Caremark will stop covering the Zepbound of Eli Lilly, a major pharmacy benefit manager that will serve as an intermediary for managing health insurance companies, large employers and other prescription drug regimes, and is now ending the zepbound of Eli Lilly, a blockbuster GLP-1 drug approved by US Food and Drug Management for historic weight management of obesity by chronic drug management in November 2023.
“This change is happening because this change can be safe, effective and costly for your condition,” CVS Caremark said in a letter sent to patients in May using Zepbound. “Remember, if you refill your current medication after July 1, 2025, you will need to pay the full fee.”
Wegovy, the GLP-1 drug for treating obesity from Lily’s competitor Novo Nordisk, is covered by plans managed by CVS Caremark and several other plans Generally, it is a drug that is not effective.
CVS covers Wegovy and the decision to rule out Zepbound is to “force manufacturers of pharmaceutical companies to compete with each other,” encouraging both Eli Lilly and Novo Nordisk to lower prices for US products.
“The terrible, high dating prices set by GLP-1 manufacturers for weight loss are the biggest barrier to patient access,” CVS Health said in a statement. “Our formal strategy maintains clinically appropriate coverage while using competition to promote lower costs.”
But pharmacy profit managers, one of the biggest, face scrutiny about their role in rising drug costs in the US.
Coverage changes apply to the most common formulary templates in CVS Caremark. If the selection became available, a subset of members taking weight loss medications chose Wegovy and Zepbound at roughly comparable levels, CVS Health said.
When it comes to weight loss, providers and patients argue that GLP-1 drugs are not one-to-one exchanges, but rather that unstable insurance coverage conflicts with the science and experience of people managing obesity as a chronic disease.
“Mainly across society, we have not embraced obesity as a long-term chronic disease, and are looking for quick fixes and quick solutions that are not real in the biology and disease process. The mindset has yet to keep up with science.”
“If decision makers don’t understand that obesity is a long-term chronic disease, then it’s when we see these exclusive policies, or these very troublesome use management practices, that are just really one after another, set up to prevent people from getting the care they need.
Trial system
Dr. Jodi Dushay, an endocrinologist at Beth Israel Deecones Medical Center and an assistant professor of medicine at Harvard Medical School, said it will take time to develop treatment plans using GLP-1 drugs that work with each patient. Some people have side effects that may cause an allergic reaction at the injection site due to one drug, or have certain side effects such as severe constipation, nausea, and stomach pain.
She often disrupts patients’ weight loss trajectories by adapting to drug changes, and trial and error can create a lot of waste due to medications that were lacking a while ago.
“As soon as these announcements (about changes to insurance coverage) come out, there’s a flood of messages from patients,” she said. “It’s extremely stressful for patients who are really good, have tolerant and feel like they’ve made their way in drug therapy, nutrition and exercise.
As Dushay looks at the patient’s medical chart, she says her stomach is shaking when she sees a small box showing insurance information.
“In this area of weight management, a small part of the chart determines the majority of their care. For me, it’s unprecedented in terms of how much insurance is important to the clinical care I offer and the options I have,” she said.
Discussion of strategies to manage insurance mandatory changes in clinical care treatment violations.
“We rarely have time to ask patients how they feel, whether they are side effects and weight loss, or general health updates,” says Dushay. “There is a loss of time in patient care and the burden of time outside of visits by doctors and pharmacists has increased dramatically.”
Another major insurance change that will occur next year will affect another large sash of Dushay patients. In January, BCBS Massachusetts excludes all GLP-1 from coverage for the treatment of obesity and reserves coverage for these drugs only if it indicates treatment of type 2 diabetes.
“The nation is facing an obesity crisis, so we are working hard to support our members by improving access to nutritious foods, physical activity programs and quality clinical care when needed,” David Merritt, senior vice president of foreign affairs for the Blue Cross Blue Shield Association, said in a statement. “We share the enthusiasm for the success of true weight loss experienced by countless patients taking GLP-1. Like new medications, we can learn to ensure that patients are set up for success. Last year, we found that about 60% of people were long enough to stay on GLP-1 and couldn’t see any meaningful weight loss.
Zepbound and Wegovy are both effective in treating obesity and are approved by the FDA to do so, but there are differences.
The study found that those who used tilzepatide injections such as Zepbound were more likely to lose weight and reach a specific weight loss target than those who used semaglutide drugs such as Wegovy. The two drugs have a different set of broader indications, and Zepbound is also approved to treat sleep apnea, for example, in people with obesity. Side effects vary, and one drug may be more acceptable than another.
Successful people with Zepbound may be able to file for exceptions after their insurance coverage changes, but CVS Caremark has limited options to actively plan changes, with many patients getting angry and worried about their health and well-being.
For Eacobacci, the changes in insurance and the emotions behind it are furious and based on prejudice.
CVS Caremark had requested that she attempt multiple alternative treatments and proved that they didn’t work before she got Zepbound’s approval this year. When she was using Wegovy, she began to approach prediabetic levels despite her A1c glucose levels being consistent with diet and exercise habits. This all changed when she started Zepbound.
“I feel better. I’m not that bloated. My movements are definitely different. I’m suited to the clothes, but I feel validated. Everything from these years tells you. “This drug actually validated some of this. ‘Hey, I need support. I can’t do this myself as much as I’m trying this.”
Changes in medication can have unnecessary and dangerous effects on physical health. Ecobacci said she won 10 pounds and saw a surge in A1C levels in a month, as well as mental health.
“Weight stigma and bias have affected us nationwide,” said Ecobatch, who is worried about many people who felt depressed after hearing news about changes in insurance coverage. “You made me jump over the hoop. I got the advance permission you needed for me. And now you – it should be illegal because it’s so shocking to take it from me.”
Coverage exceptions may be optional, but the appeal process takes time.
“It’s really frustrating to have to justify what I want to do all the time for money,” Dushay said.
For those who lose Zepbound coverage, drug maker Eli Lilly has expanded access through LillyDirect, a company platform that coordinates and fills out copay-paying patient telehealth services. Single-dose vials are available for $499 per month through the Lillydirect Zepbound Self Journey program, with the highest doses available starting July 7th.
“We are confident in Zepbound’s performance and are still committed to ensuring patients have access to the treatment they need,” Lily said in a statement.
