Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's episode of the Conquer Your Weight podcast. We are interrupting the regularly scheduled program to bring you an update about what is going on with CVS Health CVS Caremark and Zepbound coverage. We had another podcast episode planned for today, but with the news dropping last week that CVS Health CVS Caremark would no longer be covering Zepbound medication as of July 1, I was like, oh my gosh, we have to talk about this. And as you can imagine, this has been a big conversation in the obesity medicine community. We're starting to hear from our patients that they are getting letters from their insurance companies talking about the drug formulary changes. And so in the episode today, I am going to break down what this means. We're actually going to talk a little bit about what drug coverage looks like. And I'm going to apologize because it's kind of a boring topic, but it is so, so to understand or even just to start to glimpse at honestly how medications are covered in the American healthcare system is incredibly confusing and very opaque. They're not transparent with how cost of medications are covered, but I will do my best to explain how medications are covered, talk about what it means for a medication to be on formulary, off formulary, and the process of getting medications approved and covered. And then most importantly, if you are someone who is currently taking Zepbound, you are doing really well on Zepound and you're wondering how does this change affect me? We are going to talk about it, talk about some practical steps that you're going to take so that you can feel prepared as you look at what is coming down the pike over the next couple of months. So when we think about this decision, if you haven't heard last week on, I guess it was May, the first CVS Caremark announced that they would be dropping Zepbound from their formulary and that patients would be exclusively needing to use Wegovy for GLP receptor agonist coverage. Now, not a lot of details were provided, but what this likely looks like was a backend deal with Novo Nordisk. There are a lot of different medications that are on the market for the treatment of obesity, but over the last couple of years, two have really emerged as the leaders. Those are Zepbound, that is the same medication as Mounjaro. Zepbound is a tirzepatide product. It is made by Eli Lilly. The other medication is Wegovy. This is the same medication as ozempic. Wegovy is branded for weight, Ozempic is branded for type two diabetes. Those medications are semaglutide products and that is made by Novo Nordisk. So these are two separate medications made by two separate manufacturers. Now, initially the medications available on the market were Ozempic, and then a couple of years later got the indication for weight as Wegovy. Then we saw Mounjaro get approved and eventually bound. So we've had these medications on the market for the last few years and with the advent and FDA approval of tirzepatide products, so Zepbound and Mounjaro, what we have seen is that the prescribing habits have really changed in what people are taking. So Wegovy and Zepbound are both very effective medications for the medical treatment of obesity. However, what it looks like is that Zepbound is a more effective option for treatment. So typically the Wegovy medication in the clinical studies, when patients were brought up to the maximum tolerated dose of 2.4 milligrams of Wegovy, that the average weight loss was 15.6% total body weight. When you compare that to Zepbound, Zepbound is available in three, well, it's available in six different doses, but three doses were studied as treatment doses of the medication, five milligrams, 10 milligrams and 15 milligrams. The five milligram dose had an average weight loss of 15%. The 10 milligram dose had an average weight loss of 19%, and the 15 milligram dose had an average weight loss of 20%, almost 21%. And then recently in December of 2024, there was a trial called Surmount five. And in SURMOUNT-5 they looked head to head at Wegovy versus Zepbound. So in this clinical trial, typically a clinical trial will have a placebo arm. So a group of patients are taking placebo medication. In this trial, what happened was that patients were either taking Wegovy or they were taking Zepbound. They were brought up to the maximum tolerated dose of medication. So it was the top two doses of medication for the Wegovy and then for Zepbound, it was either the 10 milligram dose or the 15 milligram dose. They were continued on those medications for 72 weeks I believe. And what they saw was that patients taking Zepbound lost an average of 20.2% of their total body weight versus patients taking Wegovy lost an average of 13.7% of their total body weight. And that was a really big study because it looked at what is head to head, the same patients who were given the same information and studied at the same time. What was the average weight loss in this group of patients and showing that for the average patient, Zepbound is a more effective medication. Now interestingly, even though it's more effective, it is actually a better tolerated medication as well. There are on average about 5% of patients who discontinues Zepbound due to side effects where that number is a little bit higher, closer to 10% for patients taking the Wegovy medication. So for those of us in the obesity medicine space, I mean I think all of us like Wegovy. For a while it was the best on the market for a while until Zepbound came on the market. And we all have a lot of patients who on wavy have done very well. Many patients of mine who've achieved their weight loss goals and have done really well on Wegovy. But now that Zepbound has been on the market, it's been more effective, it's been better tolerated. Most people are prescribing Zepbound more than Wegovy. Now that's a really blanket statement I recognize. And so I won't speak to anyone, individual physician and their preferences and the patient sitting in front of them. But what I will say is that when we look at recent prescribing trends of GLP medications for the treatment of obesity, Zepbound versus Wegovy, we see that most of the new prescriptions being written in the country recently have been for Zepbound medication. And most of the total prescriptions for the treatment of obesity have been for the Zepbound medication. So all that to say, we have data to say that the Zepbound medication is more effective and it's more tolerated. So a lot of people are taking it, a lot of prescribers are prescribing it. Now, as you can imagine, Novo Nordisk that is the manufacturer of Ozempic and Wegovy has been freaking out a little bit like, oh my gosh, we are losing our market share in this area. We've been such a big performers in this area and certainly they continue to be, but not like they were a few years ago. And so there have been back market deals going on with CVS Caremark and Novo Nordisk where they have made a deal. We don't know what those prices look like, but that the cost of medication to the pharmacy benefits manager will be a lower compared to Zepbound and so therefore they dropped Zepbound and they are exclusively taking Wegovy. Now I want to spend a little bit of time going into what is a pharmacy benefits manager because I don't think most people actually know that this piece exists in the healthcare space. So when you think about getting a prescription, you have the experience of visiting your doctor, they write you a prescription, you go to your pharmacy, they tell you they run it through your insurance and then it comes back. It's either covered and there's certain copays depending on the medication, you got your medication and you go home. But what it looks like on the backend is that there are these pharmacy benefit managers and they are third party groups who manage drug benefits on behalf of health insurers. And so if you imagine a health insurance company, you imagine the pharmacies, you imagine the drug manufacturers, the pharmacy benefits managers are creating, they're managing the drug formulary. So this is the list of covered medications that your health insurance is covering. They put those into different tiers. So typically tier one is a preferred medication medications that you go to the pharmacy and you're going to pay a very small copay for like you go to get your regular blood pressure medication or cholesterol medication or antidepressant. Medications that have been around for a while are available is generic. These medications are typically tier one medications and preferred. There may be many tiers, tier two, tier three, tier four, tier five. And the higher the tier, the less preferred the medication is. So they manage these drug formularies and say, yes, we cover these medications, which ones are preferential, which ones are higher tiered and less preferred? Very commonly higher tiered medications will require a prior authorization sort of proving that the patient is a appropriate person to use this medication. And typically when we think of pharmacy benefit managers, they are negotiating drug prices. So in theory, they would be keeping drug prices as low as possible and creating bargaining between manufacturers, pharmaceutical companies, and then insurance companies and pharmacies. So they would sort of navigate this on the backend so that everybody can get fair prices. So typically if the pharmacy benefits managers were functioning as they should, they would be favoring drugs that are clinically effective and then also drugs that have been negotiated to better rates and are going to save them money. So this negotiating rates is a really important piece. So the pharmacy benefits managers negotiates rebates from pharmaceutical companies in exchange from placing their drugs either on the formulary at all or placing them in a favorable tier of the pharmacy. So pharmaceutical companies, of course, desire for their medications to be on these drug formulary list. They want those medications to be covered and they often will give rebates to the pharmacy benefits manager in order to put that drug on the list to put it on a preferable tier to have it on a lower tier. So it's a more preferable medication. They also, these pharmacy benefits managers are in charge of processing all of the claims. So when you go in, you go to get your doctor sends the prescription to the pharmacy, the pharmacy runs the benefit. When they are running the benefit, they're actually running it through your pharmacy benefits manager. They are looking to see is this medication a covered medication for you? Does this medication, is it on formulary? Do you have a deductible? In general, do you have a deductible specifically for pharmaceutical benefits? Is the dosage that your doctor prescribed appropriate? Is it an appropriate quantity? Is there anything else that's required in terms of that additional paperwork, like a prior authorization or a step therapy? And what can happen is that if any of those things are no, the medication will get denied and then you'll get a notice, Hey, we're contacting your doctor, your doctor needs to do paperwork, et cetera, et cetera. So when you look at the pharmacy benefits manager overall, this could be a very valuable thing to happen that you have someone who's looking at the prices, helping to negotiate prices on behalf of the insurance company, on behalf of the patients, on behalf of the pharmacy trying to save everyone money. The problem is is that these pharmacy benefits managers are huge conglomerate organizations. So one of the big things that's out confusing recently is CVS Caremark. People think about CVS Caremark and they're confused because they're thinking about, wait, do they mean CVS pharmacy? And no, those are actually under the same entire umbrella organization. But CVS Caremark is a pharmacy benefits manager. CVS is a chain of pharmacies, and under that entire umbrella is Aetna Health Insurance. So CVS Caremark, CVS pharmacies, Aetna Health Insurance, all of these are run by the same umbrella agency. So you've got this overall overarching umbrella agency and the negotiations are happening sort of all within, which makes it really, there's a big conflict of interest there and there's a big lack of transparency in terms of what are the actual cost of medications. You see, if you go to pick up your medication, you'll say you paid this, your insurance saved you X amount of dollars. Now the interesting thing is it's not saying your insurance paid X amount of dollars. It's saying your insurance saved you X amount of dollars. And the reason why it says saved you is because it's incorporating in all of these rebates. And so the drug manufacturers will give the medication or sell the medication, they're not giving it, but sell the medication for a lower negotiated price. The pharmacies are paying sometimes even a higher price for the medication. And the difference between that is pocketed by the pharmacy benefits manager. So there's this incredible lack of transparency of where is the money going? What are those actual rebates? Do those rebates get passed along to the insurance? Do they get passed along to the consumer or the patients or is it something that's pocketed? And then as we talked about this conglomerate agency of the pharmacy benefits manager, they own pharmacies, they own insurance companies. And this is not unique to CVS Caremark. So you've got CVS Caremark that runs CVS pharmacies or not runs, but is affiliated with CVS pharmacies. Aetna Health Insurance is wrapped up in that. Similarly, Express Scripts and Cigna health insurance are wrapped up together. OptumRx and United Healthcare Insurance are wrapped up together. So this is a very common actually that these pharmacy benefit manufacturer, pharmacy benefit managers, sorry, are affiliated then with these health insurance companies. So there's a really big conflict of interest that happens or has a potential for happening when you're not able to see where the dollars go and where those are run by the same group of people. So I'm getting a little bit off track here, but I think understanding the background of what is a pharmacy benefits manager, what is this third party agency that's doing the negotiation and are they actually looking out for the best interest of the patients, the best interests of the employers, the best interests of the insurance companies, or are they just trying to save money? And I will argue, especially as we're talking about these that Zepbound and Wegovy, the whole point of a pharmacy benefits manager is that they're looking at drugs that they are favoring drugs that are clinically effective and cost effective. And so when we think about this clinical effectiveness, are we really supporting the medication that is most clinically effective if we're saying patients cannot get Zepbound? Now when we think about the insurance coverage of obesity medications in general, this is still a really challenging area because when we look at commercial insurers, there is still an employer opt-in or opt out of coverage for weight care. So there are employers who typically are unable because of the size of their organization to afford coverage for weight care. And so they may be opted out of coverage. So if someone has opted out of coverage, you didn't have coverage before, you're not going to have coverage in the future, that may change eventually. I sounds like such a doomsday person saying that, but nothing's happening different for you on July 1st of this year, you had no coverage. Now on July 1st, you'll continue to have no coverage. If your employer is opted out, your employer is opted out. Where this matters is if your employer is opted in. So currently, if your employer is opted into coverage for the treatment of obesity, for the medical management of weight loss, what that has looked like recently or in the last year for CVS Caremark is that both Zepbound and Wegovy have been on formulary. And so patients could do either of those medications depending on what was a better option for them. So what happens now is starting July 1st is that Zepbound is no longer on formulary. It's not like it moved to a higher tier, it became less preferred. It came off of the formulary completely. And so for patients who are interested in using GLP therapy, they will be required to use Zepbound as a first-line agent. Now, excuse me, I said that backward, they will be required to use Wegovy as their first-line agent. That will be the option that's available to them. And I'm saying first-line agent, but that would be the GLP medication. There are still insurance formularies that will require step therapy. So they'll say a patient has to have used another medication before they'll have coverage. And so this still may continue to be the case despite Wego V being on the drug formulary list. They may have step therapy requirements where they say something like, okay, this patient has to have tried Contrave medication, they have to have tried Qsymia medication, they have to have tried Phentermine medication. May be others before that Wegovy would be approved for them. So that still may be the case where there are these step options. The problem comes that Zepbound is no longer on formulary. So for patients who are starting out, they will be starting with the goal of Wegovy. But for patients who are already on Zepbound, this medication is not going to continue to be covered for them and they will have to switch to a drug formulary option. Now what that should be is that they're switching to the Wegovy medication. For some people this may be fine. There are some people for whom the Wegovy medication is quite effective and is very well tolerated from a side effect standpoint. But the thing that's challenging is there are patients for whom they hit a plateau on the Wegovy medication and then when they switched over to the Zepbound medication, they started seeing their weight moving again. There are patients for whom they were not tolerating the side effects of the Wegovy medication and switching to the Zepbound medication, that medication has been better tolerated for them. And so it is not as simple as just popping over from when medication to the other. We're talking about switching from a more effective medication for most people to a medication that in the head-to-head trial is less effective. And so this can be really disappointing. Now, one of the things, it'll be interesting to see how this plays out, but as I said, Zepbound is not on the formulary at all. Now this could change. I so hope that I record this entire episode and that one and a half months from now we're getting ready for July one and it just all reverses and everything that I'm saying becomes completely irrelevant. I would absolutely, absolutely love that, but let's say that it doesn't. I'm not super hopeful. I think it'll turn around eventually, but I don't think it'll turn around by July 1. And so the patients who are on Zepbound will have to switch to Wegovy. The patients who desire to, maybe they were even on Wegovy in the past and want to continue on onto bound, they will have to ask for a drug formulary exception or a drug formulary exclusion. And when let's say you call the phone number on the back of your insurance card or if you're looking into this, the people who the customer service representatives when you call your insurance company will make it sound like, oh yeah, no big deal. Just have your physician do a drug formulary exclusion and absolutely no big deal. We can absolutely do that. I will tell you drug formulary exclusions are incredibly challenging to do in that the goal of not putting Zepbound on the formulary was that they would not be having to cover the Zepbound medication. And so when I have done drug formulary exclusions in the past for one, this is for patients only who do have medication coverage for the treatment of obesity. If you do not have, your employer has not opted into the coverage of it at this time, you do not have coverage for it. But I have done these drug formulary exclusions in the past and it is something that has taken me literal hours of writing, of documenting on the phone, having what they call peer-to-peer conversation with a physician who works at the health insurance company to sort of plead the case of why this patient needs this medication. And while they're, I suspect there'll absolutely be patients for whom we are doing this and for whom we are advocating and for whom we are going to spend the time on the phone with the insurance company to get this done. That is a huge burden to everybody. That's a burden to the physician, to the rest of the care team, to the pharmacy and everybody to the insurance company. And so they end up spending all of these additional hours. And it's not even clear to me that that much money is saved when you're spending hours on these things. And we will absolutely do that for our patients, but in our experience, those get turned down very frequently. And so while, like I said, we have been successful in other situations in the past in appealing these for our patients and doing those drug formulary exclusions, that is not as simple as they make it sound when you call the number on the back of your insurance card. What this means then. So practically, if you were taking Zepbound, you've got a letter, or if you haven't, you'll probably get one really soon. If you are insured by Aetna or your benefits are managed by CVS Caremark, you will be getting a letter in the mail saying July one, Zepbound will not be covered. So what are the options available to you? For one, I think it's really important to advocate for yourself whether this is directly to CVS Caremark, whether this is to your health insurance, whether this is to the hr, especially if you're employed at a large company, reaching out and writing a letter to those people can be really valuable. Also, writing a letter to your representatives, to your congressmen and women to advocate for the coverage of these medications in general for advocating for transparency in pharmacy benefits managers so that medications beyond the obesity medications, but particularly in this case that you're advocating for the coverage of these medications. Now between now and then, I want you to sort of stock up the medication the best you can. When you look at being able to fill the medication, it's very common depending on your insurance that you're able to fill the medication every 21 to 24 days, which means between now and July 1st, you should be able to get up to three refills of your medication, assuming that you're due for a refill right now, if you're not due for a refill right now, maybe just two. But what you don't want to be doing is running out of medication on June 30th and then on July one, you both no longer have medication and now you're needing a new prescription for your Wegovy medication. So back up, get some supply. On July one if you are taking Zepbound and if you've gotten this notice that it's no longer going to be covered, I would plan that you're switching to Wegovy. Now, if you are someone who's taken Wegovy in the past and that didn't go well, it's important that you reach out to your prescribing physician and talk to them about this. Ideally, it's something that you're doing at an appointment so that you can really have the time to work through that together to get everything really nicely documented in your most recent office visit note so that then if they are going to attempt to do that drug formulary exclusion, that they have all of the information that they need, that they can fax that off to the pharmacy in combination with other conversations and calls that need to happen. But the plan that on July 1st you would be switching to the Wegovy medication. If you're not switching into it, really understanding, okay, what is my plan for moving forward? Now you do have the option to self-pay for medications. So over the last couple of months, both for Zepbound and for Wegovy we've seen really great self-pay options come available for the Zepbound medication. What that looks like is they have vials available in the 2.5, the five, the 7.5, and the 10 10. The 2.5 milligram dose is $349 per month. The five, the 7.5 in a 10 is $499 per month. So I don't want to pretend that these are cheap prices or very affordable prices, but that is the price. And so if you are considering, Hey, what would it cost for me to stay on my bound medication? Those are the prices of those self-pay vial programs. The important thing about that is this is an entirely cash-based program. And so this isn't applying towards your insurance deductible, it's not applying towards anything else that money is spent. It's the cash pay and you're sort of circumventing needing to use the insurance, the pharmacy benefits manager, the whole thing. So you're circumventing that entire process, but there is that self-pay journey available. Now, I did mention the 2.55, 7.5 and 10, if you are on the higher two doses of Zepbound, the 12.5 milligram dose or the 15 milligram dose, those are available as pens rather than vials. And that is $650 per month. So you can download for either of those or rather the vials is just the cost, is the cost. Your physician or prescriber would need to send a prescription for the vials directly to the Lilly cash pay pharmacy. It looks a little bit different depending the electronic medical record that you're in, but it's often called LillyDirect cash pay pharmacy solutions, something like that. And then those medications are actually shipped directly to you for those vials that 2.55, 7.5 or 10 if you're on the 12.5 or 15 milligram dose, those are the pens. It's only available in the pens. They're not available on vials. Those are $650. And you can go to the Eli Lilly website, the Zepbound website to download a coupon to make those $650. So you do have the option of self-pay to continue these medications if you are not finding that you'll have insurance coverage for them. I have heard some patients or physicians rather, who've been recommending reconsideration of bariatric surgery. When we look at the effectiveness of bariatric surgery and both in terms of long-term effectiveness in terms of cost effectiveness, it is a very effective option. So if you were someone for whom maybe Zepbound had been effective but hadn't been as effective as you had desired, if you were someone for whom you had been considering that and wondering it as an option, it is reasonable to meet with a bariatric surgeon to understand what that process looks like, to understand if you would be a good candidate for good or for bad. There is pretty good insurance coverage for bariatric surgery. Many people have coverage for bariatric surgery, even if they do not have coverage for medical management of obesity. And so a lot of people do have that door open for them. Doesn't mean that you should feel forced into taking that or anything, but just aware that that is an option for some people and maybe something worth considering. So if you are on Zepbound and you are facing this, I am so sorry. It has to be just the most stressful situation as a patient to feel like you have found something. It's working. Of course, you want to continue that medication. And I would encourage you starting now, reach out to your care team, schedule an appointment, make sure to advocate yourself through this process. Don't be someone who slips through the cracks. I think one of the things that I'm most worried about is the group of patients for whom they've been taking Zepbound, they've been doing phenomenally, and then maybe just don't even get transitioned to Wegovy. So maybe they don't have a follow-up appointment or it slips through the cracks because life gets busy and all of the things, and now they're not on medication at all, and they see that they start undoing some of that work that they've done. And so I'm sorry that you're in this position and being an advocate for yourself is one of the best things that you can do. Work with a care team who will advocate for you as well. Certainly me and my team, we will do absolutely anything we can to advocate for our patients. We write so many stinking letters to insurance companies in order to help get medications covered, to appeal those, to do those drug formulary exceptions. And for good or bad, we've gotten really good at the process. And so you deserve a physician and a care team who is going to support you. Alongside of this, if you were looking for care in Illinois, Tennessee, or Virginia where I'm licensed to practice medicine, I would love to support you. I also see patients in person in Charlottesville, Virginia. If you're interested in learning more about me and my medical practice, you can visit www.sarahstombaughmd.com. Thank you so much for joining me today. If you have questions, as always, you can send me an email info@sarahstombaughmd.com. I know that this is super frustrating. A lot of things are evolving. We'll be making updates on social media as well, so follow me there and I hope to be able to help you. And like I said, maybe this will be a moot conversation. Everything will get reversed, everything will be covered, fingers crossed. But until then, stay tuned for more updates. We'll see you all next week. Bye-bye.