A class-action lawsuit was filed last week against CVS Caremark in the Southern District of New York over its decision to replace Eli Lilly’s popular GLP-1 weight-loss drug Zepbound with Wegovy from Novo Nordisk.
The coverage change made in July applies to the most common formulary template, which represents between 25 million and 30 million individuals overall, although the lawsuit was filed on behalf of two patients. The plaintiffs alleged that the pharmacy benefits manager is violating its fiduciary duty under the Employee Retirement Income Security Act, because their providers prescribed Zepbound as medically necessary for them.
"Plaintiffs’ claims for coverage for their Zepbound prescriptions were improperly denied, and the arbitrary and capricious denials issued by CVS Caremark ignored the language of the underlying plans, the reasons why Zepbound is medically necessary for each plaintiff and overruled the recommendations of plaintiffs’ skilled and knowledgeable medical providers," the lawsuit said.
The plaintiffs also challenge Caremark’s assertion that the two GLP-1 drugs are nearly identical. "Because of their different methods of action, different clinical outcomes and different side effects for individual patients, Zepbound and Wegovy are not clinically interchangeable," the complaint said.
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, CNN reported. The two drugs have different sets of broader indications, and side effects also can vary
Caremark disagrees, maintaining that Wegovy and Zepbound are “two clinically similar products.” Requiring the drug manufacturers to compete with one another on price will encourage both Eli Lilly and Novo Nordisk to lower prices for their products in the United States and broaden access, David Whitrap, vice president of external affairs for CVS Health, told CNN.
“Our formulary strategy maintains clinically appropriate coverage while using competition to drive lower costs,” he said. “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.”
The company also has a medical exceptions process for the “rare cases” in which “on-formulary options prove ineffective or cause harmful side effects,” he added.
The plaintiffs asked the court restore coverage of Zepbound for people on CVS Caremark plans and award other “appropriate equitable relief.”
© Touchpoint Markets, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to TMSalesOperations@arc-network.com. For more information visit Asset & Logo Licensing.