Understanding BCBS Weight Loss Medication Coverage

Blue Cross Blue Shield (BCBS) offers various plans with differing levels of coverage for weight loss medications. This article aims to provide clarity on how to navigate BCBS's weight loss medication coverage, eligibility criteria, and available resources. It is estimated that one in three American adults are obese, making weight management a crucial aspect of overall health.

Checking Your Plan's Coverage

The first step in determining whether your BCBS plan covers weight loss medications is to check your specific plan details. Here’s how:

1. Online Account Access: Log in to your BCBS member account.
2. Navigate to Prescriptions: From the main menu, select "Prescriptions".
3. Find Medicines: Choose "Find Medicines" and then "Search Medicines". This will redirect you to Prime Therapeutics, a pharmacy solutions company contracted by BCBS.
4. Search the Formulary: Search for your specific medication on the formulary to see if it is covered.

It’s important to note that even if a weight loss medication is listed on the formulary, it will not be covered if your plan does not include weight loss benefits. For definitive information regarding your coverage, contact your employer directly.

Out-of-Pocket Costs

If your insurance plan does not cover weight loss medications, you will have to pay for them out of pocket. This can be a significant expense, so it's crucial to explore all available options and resources.

Prior Authorization and Medical Necessity

Even if your plan includes weight loss benefits, you may need prior authorization for certain medications.

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1. Prior Authorization Form: Ask your prescribing healthcare provider to complete the Prior Authorization/Medical Necessity Determination form. This form can be found on the Forms page of Prime Therapeutics.
2. Submission: Submit the completed form to BCBS for review.

Federal Employee Program (FEP) Changes

For members with FEP Blue Standard® and FEP Blue Basic® plans, it's important to be aware of upcoming changes. Beginning January 1, 2025, the tiers for some weight loss GLP-1 drugs will change. Stay informed about these changes to understand how they may affect your coverage and costs.

Weight Management Programs and Resources

BCBS offers several programs and resources to support members in their weight management journey:

1. Weight Management Program by Livongo®: Eligible members can access a digital scale and ongoing support to manage their weight and improve their health. This program is available to members 13 and older who meet specific criteria, such as having a pediatric or adult pharmacy or medical claim with a BMI of 25 or higher within the last three years. Members living overseas must have a valid APO, DPO, or FPO address.
2. Blue365®: Through Blue365®, members can access handpicked deals on national health and wellness brands, helping them achieve their fitness goals on a budget.
3. Personalized Action Plan: Get a personalized action plan and track progress toward your health goals.
4. Registered Dietitian: Connect with a registered dietician who can evaluate your nutritional needs and help you develop personalized meal plans via phone or computer.
5. FEP Blue Focus®: FEP Blue Focus® members can get rewarded for having their annual physical every year.

Coverage for Weight-Loss Procedures

In addition to medications, BCBS FEP also covers procedures to treat morbid obesity for Service Benefit Plan members who meet eligibility criteria and get prior approval. Note that prior approval is required for surgery for morbid obesity.

Pharmacy Network

BCBS has a vast network of over 55,000 preferred retail pharmacies nationwide to fill your prescriptions. For members with complex health conditions who need specialty drugs, including oral, inhaled, injected, and infused drugs, BCBS provides access to these medications. Preferred specialty and Non-preferred specialty drugs are limited to a 30-day supply; only one fill allowed.

For members with Medicare Part B primary only, BCBS covers a 22 to 90-day supply of medications.

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Since there are no in-network retail pharmacies overseas, you need to pay for your prescriptions out-of-pocket and then submit your receipts and a completed claim form to get reimbursed. territory.

Drug List Exceptions

If a medication is not on the BCBS drug list, you, your prescribing health care provider, or your authorized representative can request a Drug List exception. To request this exception, you, your prescriber, or your authorized representative, will need to send BCBSTX documentation. To begin this process, you or your prescribing health care provider can call the number on your ID card for more information or fill out and submit the Prescription Drug Coverage Exception form. BCBSTX will let you, your prescriber (or authorized representative) know the benefit coverage decision within 72 hours of receiving your request. If the coverage request is denied, BCBSTX will let you and your prescriber (or authorized representative) know why it was denied and may advise you of a covered alternative drug (if applicable).

If you have a health condition and failure to take the medication may pose a risk to your life, health or keep you from regaining maximum function, or your current drug therapy uses a non-covered drug, you, your prescriber, or your authorized representative, may be able to ask for an expedited review process. BCBSTX will let you, your prescriber (or authorized representative) know the coverage decision within 24 hours of receiving your request for an expedited review. If the coverage request is denied, BCBSTX will let you and your prescriber (or authorized representative) know why it was denied and may advise you of a covered alternative drug (if applicable). Call the number on your ID card if you have any questions.

GLP-1 Medications and Discontinuation Rates

Recent studies have shown that despite the increased demand for weight loss drugs like GLP-1s, a significant number of patients discontinue use before experiencing clinically meaningful health benefits. A study conducted by Blue Cross Blue Shield Association (BCBSA) found that 58% of patients discontinue use before reaching a clinically meaningful health benefit.

This study underscores the need for more research into these medications to better understand which patients will benefit, how to sustain their success, and how to manage the costs associated with them. According to the study conducted by BHI, most GLP-1 prescriptions came from primary care providers, but patients who received their prescriptions from an endocrinologist or obesity medicine specialist were more likely to stick with the treatment. BHI data indicates that patients facing the greatest socioeconomic barriers to health care, such as cost, transportation and language barriers were less likely to continue treatment, as were adults under age 35.

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Important Considerations

1. Treatment Decisions: Treatment decisions are between you and your doctor. While doctors are encouraged to prescribe drugs on the list, it is ultimately up to the healthcare provider and patient to determine the best course of action.
2. Safety and Efficacy: Drugs on the drug list are chosen based on their safety, cost, and how well they work.
3. Underlying Conditions: It's important to consider any underlying health conditions and potential risks associated with weight loss medications.

tags: #bcbs #weight #loss #medication #coverage