Major insurance changes are coming to GLP-1 drugs for weight loss. Here's how that could affect patients

Yahoo

3 days ago

Last week, Tara Eacobacci had an appointment with her doctor that was devoted exclusively to the topic of health insurance. A major change to her prescription benefits meant the medication she was using to manage her weight – a treatment that had taken years of trial and error to get right – would no longer be covered by insurance.
'I'm completely outraged,' Eacobacci said. 'It's not only causing me stress, but it is making me angry.'
Starting Tuesday, CVS Caremark – a major pharmacy benefit manager that serves as a middleman for health insurers, large employers and other payers to manage their prescription drug plans – will stop covering Eli Lilly's Zepbound, a blockbuster GLP-1 drug that has been approved by the US Food and Drug Administration since November 2023 for chronic weight management in adults with obesity or who are overweight.
'This change is happening because there's another covered medication that's safe and effective for your condition and may cost less,' CVS Caremark said in a letter sent in May to its patients using Zepbound. 'Please keep in mind, if you refill your current medication on or after 7/1/2025, you'll need to pay the full cost.'
Wegovy, the GLP-1 medication to treat obesity from Lilly competitor Novo Nordisk, will still be covered under plans managed by CVS Caremark, along with a few other medications that are generally less effective.
CVS says the decision to cover Wegovy and exclude Zepbound is 'forcing the drug manufacturers to compete with one another' and will encourage both Eli Lilly and Novo Nordisk to lower prices for their products in the US.
'The egregiously high list prices set by drug manufacturers of GLP-1s for weight loss are the single biggest barrier to patient access,' CVS Health said in a statement. 'Our formulary strategy maintains clinically appropriate coverage while using competition to drive lower costs.'
But pharmacy benefit managers – of which CVS Caremark is one of the largest – have faced scrutiny for their role in rising drug costs in the US.
When it comes to weight loss, providers and patients argue that GLP-1 medications are not a one-for-one swap and that volatile insurance coverage contradicts the science and experience of people managing obesity as a chronic disease.
'Largely across society, we don't accept obesity as a long-term chronic disease, and we're still looking for quick fixes and quick solutions where that's not the reality of the biology and disease process. The mindsets have not caught up with the science yet,' said Dr. Tracy Zvenyach, director of policy strategy and alliances at the Obesity Action Coalition, a nonprofit advocacy group.
'If decision-makers do not understand obesity to be a long-term chronic disease, that's when we see these exclusionary policies or these very, very cumbersome utilization management practices that really just set up one barrier after another to prevent people from getting the care that they need. It's unacceptable. We don't do that with other chronic diseases.'
It takes time to develop a treatment plan with GLP-1 drugs that works with each individual patient, said Dr. Jody Dushay, an endocrinologist at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School. Some people might have an allergic reaction at the injection site for one medication or have worse side effects – such as severe constipation, nausea or stomach pain – with one than another.
Adapting to a change in medication will often interrupt a patient's weight-loss trajectory, she said, and the trial-and-error could create a lot of waste for medications that were in shortage not long ago.
'As soon as these announcements [about insurance coverage changes] come out, I get flooded with messages from patients,' she said. 'It's very stressful for patients who have been doing really well, who are having good tolerance and feel like they have hit their stride in terms of medication, nutrition and exercise. Everything is heading in the right direction, and then having to switch can be very disruptive.'
When Dushay is looking through a patient's medical chart, she says, her stomach churns when she sees the little box that indicates their insurance information.
'In this field of weight management, that little teeny part of the chart dictates so much of their care. For me, it's unprecedented in terms of how much insurance matters for the clinical care that I'm providing and the choices that I have,' she said.
And discussing strategies to manage insurance-mandated changes in treatment infringes on clinical care.
'There is barely time to ask the patient how they are feeling, about side effects and weight loss and general health updates,' Dushay said. 'There is a loss of time for patient care and a huge increase in time burden outside the visit for doctors and pharmacists.'
Another major insurance change coming next year will affect another large swath of Dushay's patients: In January, BCBS Massachusetts will be excluding all GLP-1s from coverage for treatment of obesity, reserving coverage for these drugs only when indicated to treat type 2 diabetes.
'The nation is facing an obesity crisis. That's why we work hard to support our members achieve a healthy weight by improving access to nutritious food, physical activity programs, and quality clinical care when needed,' David Merritt, senior vice president of external affairs for the Blue Cross Blue Shield Association, said in a statement. 'We share the enthusiasm for the real weight loss success experienced by the countless patients taking GLP-1s. As with any new medication, there is more to learn to ensure patients are set up for success. Last year, we published a study that found roughly 60% of people do not stay on GLP-1s long enough to see meaningful weight loss. While adherence is improving, we need more data to ensure these costly medications deliver long-term value for patients and the health care system.'
Zepbound and Wegovy are both effective at treating obesity and approved by the FDA to do so, but there are differences.
Studies have found 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 in people with obesity, for example. Side effects can vary, too, sometimes making one medication more tolerable than the another.
People who have had success with Zepbound may be able to file for an exception after the insurance coverage changes, but CVS Caremark has limited options to proactively plan for the change, leaving many patients angry and concerned about their health and well-being.
For Eacobacci, the insurance changes and the sentiment behind them are enraging – and based in prejudice.
CVS Caremark had required that she try multiple alternate treatments and prove that they didn't work before she was approved for Zepbound this year. When she was on Wegovy, she said, her A1C glucose levels started to rise close to prediabetic levels despite consistent diet and exercise habits. This all changed once she started Zepbound.
'I feel better. I'm not as bloated. My movement is definitely different. I fit into my clothes, but I also feel validated – because all of these years, doctors say to you, 'Oh, you can't eat all that cake and candy,' and they don't believe that you're not,' Eacobacci said. 'The medication actually validated some of this. Like, 'hey, I do need support. I can't do this on my own as much as I'm trying.' '
Medication changes could have unnecessarily dangerous impacts on physical health – Eacobacci said she gained 10 pounds and saw her A1C levels spike in just one month without the medication – as well as mental health.
'Weight stigma and bias has affected us nationwide,' said Eacobacci, who is worried about many people she knows who have felt depressed after the hearing the news about changes in insurance coverage. 'You made me jump through hoops. I got the prior authorization you required for me, and now you're – mid-year – taking it away from me is so impactful that it should be illegal.'
Although coverage exceptions may be an option, the appeals process takes time.
'It gets really, really frustrating to have to justify what I want to do all the time just because of money,' Dushay said.
For people who do lose coverage of Zepbound, drugmaker Eli Lilly has expanded access through LillyDirect, a company platform that helps coordinate telehealth services and fill prescriptions for patients who pay out-of-pocket. Single-dose vials are available for $499 per month through the LillyDirect Zepbound Self Pay Journey Program, with the highest doses available beginning July 7.
'We're confident in Zepbound's performance and remain committed to ensuring patients have access to the treatment they need,' Lilly said in a statement.