The Patients Forced to Switch From Zepbound to Wegovy

Some shift to save money in response to CVS Caremark restrictions; others appeal for Zepbound coverage, citing better weight-loss results

Katie Duffy had already lost 50 pounds on Zepbound when she learned some unsettling news: Her drug-benefit plan would no longer cover the medication because of new, more favorable pricing for another drug, Wegovy .

The acupuncturist was devastated. She had tried various methods to lose weight over the years including diet and exercise until one finally stuck— Eli Lilly ’s leading weight-loss drug Zepbound . The 50-year-old is now on Novo Nordisk ’s Wegovy, but worries because it is less effective. Studies have shown Wegovy helps people lose less weight, on average, than Zepbound. Duffy hopes Wegovy will at least help her maintain her current healthy weight, even if she doesn’t lose additional weight.

“To have the rug pulled out from under me is very disheartening,” said Duffy. “I just wish they would trust my doctor to prescribe the best thing for me. That’s why we pay into health insurance.”

Duffy is among thousands of Americans being forced to switch from Zepbound to Wegovy as a result of new coverage restrictions by pharmacy-benefit manager CVS Caremark , a unit of CVS Health that manages drug plans for employers and insurers. It is the most high-profile example in recent years of something that critics call “nonmedical switching,” in which a PBM ends coverage of one drug and provides more favorable coverage of a similar drug, usually because it has negotiated better pricing.

Since the change took effect, about 95% of weight-loss prescriptions filled for affected CVS members have been for Wegovy, according to CVS. Previously, it was about a 50-50 split between Zepbound and Wegovy. People are reluctantly switching to Wegovy from Zepbound to avoid much higher out-of-pocket costs—more than $600 a month today compared with an average fixed copay of $80 a month before CVS implemented its coverage changes.

While many patients have made the switch, others are still seeking medical exceptions from CVS that would enable continued coverage of Zepbound. If CVS denies their requests, some are planning further appeals. Some patients also plan to pony up the cash however they can to continue taking Zepbound. The steering from one drug to another could hurt care, patient advocates and doctors say.

“We are concerned about how it decreases access to care, and the potential negative health effects that it has for patients,” said Tracy Zvenyach , director of policy strategy and alliances at the Obesity Action Coalition, a patient advocacy group.

At the heart of the issue is how effective each drug is for individuals. Zepbound and Wegovy aren’t identical, said Dr. Holly Lofton , an obesity-treatment specialist at NYU Langone Health.

Zepbound has been shown in studies to help people lose more than 20% of their body weight, versus between 15% and 18% for Wegovy. She said some patients on Wegovy stop losing weight before reaching their goals, while Zepbound can get them closer.

“Many times we have switched patients who were on Wegovy for a long time to Zepbound and sometimes they saw additional weight loss or had fewer side effects,” said Lofton. “Those patients aren’t happy they are being mandated to switch back to a medication they either did not tolerate or had suboptimal results with.”

CVS’s change in coverage began on July 1 for its most common formulary template, or list of preferred drugs. CVS makes the list, and it is up to its clients—employer-based and other health plans—whether to follow the formularies in their drug coverage decisions.

CVS said it was making the change because list prices for weight-loss drugs are too high, and it was able to negotiate lower net pricing from Novo Nordisk for Wegovy than what Lilly was offering for Zepbound. It said the decision will save CVS clients about 10% to 15% on spending of weight-loss drugs. With favorable coverage, patients typically have lower out-of-pocket costs than for a drug that is not preferred by the PBM.

CVS acknowledged that Zepbound has been shown to help people lose more weight than Wegovy, but that Wegovy can still help many people lose significant weight. And, Wegovy has been proven to reduce the risk of heart attacks and strokes in people with excess weight.

“The issue is they’re too expensive ,” said Dr. Michelle Gourdine , chief medical officer of CVS Caremark. “So what that means is that because of egregious high prices that pharma manufacturers have set for these drugs, many people who qualify for them can’t afford them.”

Novo Nordisk said CVS’s decision speaks to the benefits of Wegovy. A Novo Nordisk spokeswoman said Wegovy has a range of approved uses, including weight loss in children 12 and older, as well as for reducing cardiovascular risk in adults. It is being studied for additional uses including treating liver disease.

Lilly said it has proactively communicated with many CVS patients and provided information about its patient-support programs. Lilly is also encouraging patients to seek exceptions and appeals with CVS to maintain Zepbound coverage. The company has posted a downloadable form letter on its website that doctors can submit to CVS on behalf of patients.

About 200,000 CVS members on Zepbound have been affected, analysts say. U.S. total prescription volume for Zepbound in the week ended July 18 dropped 4% from the week before, while Wegovy prescriptions rose nearly 10%, according to J.P. Morgan analysts, citing Iqvia data. Copays for Wegovy remain around $80 a month.

NYU Langone’s Lofton estimates that about 2,000 of her practice’s 5,000 patients are CVS members taking Zepbound. Some have switched to Wegovy, but others are seeking exceptions so that CVS plans continue to pay for Zepbound.

Joseph Zucchi , a physician assistant treating obesity patients at Transition Medical Weight Loss in Salem, N.H., said CVS has approved switching some of his Zepbound patients to Lilly’s diabetes drug Mounjaro —which has the exact same main ingredient as Zepbound.

These are patients who previously tried Wegovy and couldn’t tolerate its side effects or were allergic to it, he said. He hasn’t had success getting CVS coverage for Zepbound users who haven’t previously tried Wegovy.

Tara Eacobacci had taken Wegovy for a few years, before it stopped working as well last year. The New York administrative assistant started to regain some of her lost weight and her blood-sugar levels started going up, so her doctor switched her to Lilly’s Zepbound.

“It has helped me control my weight and my eating in a way that no other drug has been able to,” she said.

Since the change in CVS’s coverage, Eacobacci and her doctor have sought a medical exception to allow continued coverage. While awaiting word, she stretched out her remaining Zepbound supply by taking it every 10 days instead of once a week.

Initially, CVS denied the request for continued coverage of Zepbound, prompting her doctor to seek authorization for coverage of Mounjaro, which CVS granted. Later, after an appeal, CVS also approved her use of Zepbound. But Eacobacci said she would use Mounjaro because it should be covered for at least three years and she isn’t sure how long Zepbound will be covered.

Eacobacci said she is relieved that Mounjaro will be covered. Still, the “the hoops I had to jump through, the stress I endured—it shouldn’t have been this hard,” she said.

Write to Peter Loftus at Peter.Loftus@wsj.com