Tens of thousands of Americans will soon be forced to switch from Zepbound to Wegovy for obesity treatment, despite evidence that Zepbound leads to greater weight loss, due to a decision by CVS Health’s Caremark that highlights how insurance policies—not medical efficacy—often determine patient care.
At a Glance
- CVS Caremark’s decision to exclude Zepbound in favor of Wegovy will affect thousands of patients despite research showing Zepbound produces greater weight loss
- Patients like Ellen Davis, who lost 85 pounds on Zepbound, face disruption to successful treatment plans
- Weight loss medications can cost over $12,700 annually without insurance, making coverage decisions critical for patient access
- The FDA recently approved Wegovy for reducing cardiovascular risk, potentially opening Medicare coverage to 3.6 million beneficiaries
- Insurance coverage remains the greatest barrier to obesity treatment in the United States according to medical experts
The Growing Divide Between Medical Efficacy and Insurance Coverage
The obesity treatment landscape is being dramatically reshaped by insurance decisions rather than clinical evidence. CVS Health’s Caremark recently decided to exclude Zepbound (tirzepatide) from its formulary despite studies showing it leads to greater weight loss than Wegovy (semaglutide). This decision will force tens of thousands of Americans to switch medications regardless of their current treatment success. For patients with cardiovascular disease and obesity, these medications represent more than just weight management—they offer significant health improvements including reduced risk of heart attack and stroke.
For patients like Ellen Davis, a 63-year-old from Huntington, Massachusetts, this insurance-driven switch threatens to disrupt life-changing progress. After losing 85 pounds and experiencing significant health improvements during a year on Zepbound, she now faces uncertainty about her treatment future. Similar cases are emerging nationwide as patients discover their successful treatments are being determined by insurance formularies rather than medical effectiveness or individual response to medications.
The Financial Reality of Obesity Medication Access
The financial implications of these coverage decisions are staggering for patients. Without insurance, Zepbound can cost over $12,700 annually, while Wegovy carries similar pricing. When insurance coverage changes, patients face impossible choices. Debbie Halstead, who experienced significant health improvements including a 60-pound weight loss and reduced blood pressure using Wegovy, watched her monthly cost skyrocket from $25 to $713 when her Blue Cross Blue Shield plan altered its coverage of GLP-1 medications.
These abrupt coverage changes leave patients scrambling for alternatives, including seeking compounded versions of these medications—a practice that comes with its own risks and regulatory challenges. Many are forced to discontinue treatment altogether, undermining years of progress and potentially allowing serious health conditions to worsen. The high costs have driven some patients to ration medications or abandon treatment entirely, even when the drugs have proven highly effective for their individual cases.
Evolving Policy Landscape and Future Access
The future of obesity medication access may be shifting. The Biden administration proposed extending obesity drug coverage to more Medicare and Medicaid enrollees by 2026, though the plan’s future remains uncertain. A significant development came when the FDA approved a new use for Wegovy to reduce heart attack and stroke risk in overweight or obese individuals with cardiovascular disease. This approval potentially opens Medicare coverage to an estimated 3.6 million beneficiaries who previously had no coverage for these medications.
The American Medical Association’s recognition of obesity as a disease has strengthened advocacy for insurance coverage of weight loss medications. The Treat and Reduce Obesity Act of 2023 aims to include these medications in Medicare coverage, potentially addressing a critical gap in care for older Americans. Meanwhile, Medicare could begin negotiating semaglutide prices as early as 2025, potentially reducing costs by 2027—though this provides little comfort to patients currently facing treatment disruptions.
Navigating Treatment Transitions
For patients forced to switch between medications, the transition presents both medical and practical challenges. The medications work through similar but distinct mechanisms—Wegovy targets GLP-1 receptors while Zepbound affects both GLP-1 and GIP receptors. This difference contributes to Zepbound’s reported greater efficacy in weight reduction. Patients switching between these medications may experience different side effect profiles, varying efficacy, and potentially need dosage adjustments under medical supervision.
Healthcare providers find themselves caught between insurance mandates and optimal patient care. Many physicians are developing strategies to help patients appeal coverage denials, navigate manufacturer assistance programs, or find alternative treatment approaches. The disruption to established treatment plans creates additional administrative burdens for medical practices while potentially compromising patient outcomes. For now, the geography of obesity care in America remains defined less by medical science and more by insurance coverage maps.
