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Class action lawsuits

CVS Caremark Faces Lawsuit Over Decision to Drop Zepbound Coverage

Strategic Insights

— 2 min read

A class-action lawsuit has been filed against CVS Caremark over its decision to stop covering Zepbound, a GLP-1 drug used to treat obesity. The lawsuit alleges that the change from CVS Caremark to covering Wegovy, another GLP-1 drug, violates standards for evaluating the medical necessity of treatment options. Patients and their doctors say the treatments are not medically interchangeable, despite CVS Caremark claiming that Wegovy and Zepbound are "two clinically similar products." The lawsuit seeks to restore coverage of Zepbound for people on CVS Caremark plans and award other "appropriate equitable relief."

Key Takeaways:

  • A class-action lawsuit has been filed against CVS Caremark over its decision to stop covering Zepbound, a GLP-1 drug used to treat obesity.
  • The lawsuit alleges that the change from CVS Caremark to covering Wegovy, another GLP-1 drug, violates standards for evaluating the medical necessity of treatment options.
  • Zepbound and Wegovy are not medically interchangeable, according to patients and their doctors, despite CVS Caremark claiming that they are "two clinically similar products."
  • The lawsuit seeks to restore coverage of Zepbound for people on CVS Caremark plans and award other "appropriate equitable relief."
  • John Cole, a patient who lost 60 pounds on Zepbound, has spent over 100 hours working to regain coverage for the medication.
  • More than 8 in 10 people who stopped using Zepbound switched to Wegovy, according to an analysis of electronic health records by Truveta.
  • 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.
  • CVS Caremark maintains that Wegovy and Zepbound are "two clinically similar products" and that forcing the drug manufacturers to compete with each other on price will encourage both to lower prices in the US and broaden access overall.
  • The medical exceptions process is available for "rare cases" in which "on-formulary options prove ineffective or cause harmful side effects."
  • Dr. Jody Dushay, an endocrinologist at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, says that switching between Zepbound and Wegovy can be burdensome due to the need for trial and error to get the dosing right.

Statistics:

  • About 1 in 10 people using Zepbound switched to a different GLP-1 in July, which is about 16 times more than typical.
  • The vast majority of those who stopped using Zepbound - more than 8 in 10 - switched to Wegovy.
  • Overall prescribing rates for Zepbound in July grew at about half the pace they had been for the past year and a half.
  • New prescriptions for Zepbound fell for the first time in nearly a year.
  • First-time prescriptions for Wegovy saw the largest monthly increase in more than a year.

Sources:

  • CNN, "CVS Caremark sued over decision to drop coverage of Zepbound, a drug used to treat obesity"
  • Eli Lilly press release, "Zepbound (tirzepatide) Receives FDA Approval for Treatment of Adults with Obesity"
  • Novo Nordisk press release, "WEGOVY (semaglutide) Receives FDA Approval for the Treatment of Adults with Obesity"
  • CVS Caremark press release, "CVS Caremark Announces Formulary Update for US Marketplace Plans"
  • Truveta press release, "New Data from Truveta Highlights the Impact of CVS Caremark's Formulary Change on GLP-1 Medications"

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