What is the story about?
What's Happening?
CVS Caremark is facing a class action lawsuit following its decision to remove Eli Lilly's GLP-1 drug Zepbound from its formularies, effective July 1. The pharmacy benefit manager has instead given preferred status to Novo Nordisk's GLP-1 drug Wegovy, claiming the two medications are interchangeable. The lawsuit, filed in New York's Southern District Court, alleges that CVS Caremark violated its fiduciary duty under the Employee Retirement Income Security Act by denying coverage for Zepbound, which some providers have deemed medically necessary for certain patients. The plaintiffs argue that Zepbound and Wegovy are not clinically interchangeable due to their different molecular compositions and clinical outcomes. Zepbound is approved by the FDA for managing obesity and sleep apnea, and some patients have reported milder symptoms with tirzepatide compared to semaglutide.
Why It's Important?
The lawsuit against CVS Caremark highlights significant concerns regarding pharmacy benefit management practices and their impact on patient care. The decision to favor Wegovy over Zepbound could affect patients who rely on Zepbound for its specific medical benefits, such as managing sleep apnea. This case underscores the broader issue of how formulary decisions can influence drug accessibility and affordability, potentially affecting patient outcomes. The outcome of this lawsuit could set a precedent for how pharmacy benefit managers make formulary decisions, impacting the pharmaceutical industry and healthcare providers. Employers and plan sponsors are particularly interested in this case, as GLP-1 drugs are a major cost driver in pharmacy benefits.
What's Next?
CVS Caremark plans to defend itself against the lawsuit, asserting that its formulary strategy is designed to maintain clinically appropriate coverage while promoting competition to lower costs. The company has an exemption process in place for necessary cases. The legal proceedings will likely explore the clinical interchangeability of Zepbound and Wegovy, and whether CVS Caremark's formulary decisions align with fiduciary responsibilities. Stakeholders, including healthcare providers and patients, will be closely monitoring the case for its implications on drug coverage policies and patient access to necessary medications.
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