Navigating BCBSTX Coverage for Weight Loss Medications: A Comprehensive Guide

Blue Cross Blue Shield of Texas (BCBSTX) offers various options for weight loss medication coverage, but understanding the specifics can be complex. This article provides a detailed overview of BCBSTX's policies, programs, and factors influencing coverage for medications like Zepbound and Wegovy.

Understanding BCBS Coverage for Zepbound

Overview of BCBS Plans

Blue Cross Blue Shield (BCBS) provides a range of health insurance plans, including HMO, PPO, and POS options, each with unique coverage guidelines. It's crucial to review your specific BCBS plan to understand the extent of medication coverage, including Zepbound.

Prescription Drug Benefits

BCBS plans often include prescription drug benefits, but the level of coverage varies. Some plans may cover Zepbound, while others may not, depending on factors such as the plan type and structure.

Factors Influencing Coverage

Several factors influence whether BCBS covers Zepbound:

• Plan Type and Structure: Different plans offer varying levels of prescription drug coverage.
• Geographical Location: Coverage options can vary depending on the state or region.
• Clinical Necessity: The patient's medical history and current health condition must indicate the need for Zepbound.
• Regulatory Approvals: FDA approval status and guidelines can affect coverage decisions.

Steps to Determine If BCBS Covers Zepbound

1. Review Your BCBS Plan Documents: Carefully read your plan documents to understand coverage details and guidelines.
2. Consult Your Healthcare Provider: Discuss the potential benefits of Zepbound with your doctor, who can provide insights and guidance regarding the medication and its coverage.
3. Contact BCBS Directly: Inquire about Zepbound coverage, providing your medical condition and supporting documentation.

Prior Authorization and Appeals

BCBS may require prior authorization for Zepbound, necessitating additional information from your healthcare provider to demonstrate medical necessity. If coverage is denied, you have the right to appeal, presenting additional evidence to support your case.

Read also: Guide to BCBSTX and Weight Loss

Eligibility Criteria for Zepbound Coverage Under BCBS

• Medical Conditions Required: Patients must have a diagnosis of type 2 diabetes or manage weight-related health issues such as high blood pressure, cardiovascular disease, or sleep apnea, documented by a healthcare provider.
• Age and BMI Requirements: Patients must be at least 18 years old with a Body Mass Index (BMI) of 30 or higher, or a BMI of 27 or higher with at least one weight-related health condition.
• Previous Weight Loss Attempts: BCBS often requires proof of previous unsuccessful weight loss attempts through a structured program or medical supervision.

Exclusions and Limitations

You may not be eligible if enrolled in any state, federal, or government-funded healthcare program. BCBS may also require prior authorization.

How to Verify Your Zepbound Coverage with BCBS

1. Check Your Online Account: Log in to your BCBS account to find detailed information about your benefits, including prescription drug coverage.
2. Contact Customer Service: Call the number on your insurance card for specific details about your coverage, including any requirements for precertification or prior authorization.
3. Consulting Your HR Department: If you receive insurance through your employer, your HR department can be a valuable resource.

Factors That Influence BCBS Coverage for Zepbound

• Plan Type and Structure: HMO, PPO, and POS plans have different coverage rules.
• Geographical Location: BCBS plans can vary significantly by state or region.
• Clinical Necessity and Medical History: BCBS often requires proof that Zepbound is medically necessary.
• Regulatory Approvals and Guidelines: Changes in FDA approvals can affect BCBS coverage.

Costs Associated with Zepbound Under BCBS Plans

• Co-payment Ranges: Co-payments can range from $25 to over $100 per month, depending on your plan.
• Out-of-Pocket Expenses: Without insurance, a 28-day supply of Zepbound can cost around $1,060, totaling approximately $13,800 per year.
• Financial Assistance Programs: Explore potential savings from manufacturer discounts or financial assistance programs.

Understanding the Denial Reasons

If your Blue Cross Blue Shield (BCBS) plan denies coverage for Zepbound, the first step is to understand why. Call your insurance company to find out the specific reasons for the denial. Sometimes, they may need more information or documentation from your healthcare provider.

Steps to Appeal the Decision

If you believe the denial was incorrect, you have the right to appeal. Follow these steps:

1. Gather Documentation: Collect all necessary documents, including medical records and a letter from your healthcare provider explaining why Zepbound is medically necessary.
2. Submit an Appeal: Write a formal letter to BCBS, explaining why the medication should be covered. Include all supporting documents.
3. Follow Up: After submitting your appeal, follow up with BCBS to ensure they received all the necessary information.

Alternative Treatment Options

If your appeal is unsuccessful, consider other options. Your healthcare provider may recommend lifestyle changes like diet and exercise. Additionally, other weight loss medications, such as Wegovy, might be covered by BCBS.

Blue Cross Blue Shield Wegovy Prior Authorization Criteria

BCBS may cover Wegovy depending on your BMI and weight-related health conditions, often requiring prior authorization.

Read also: Weight Loss Guide Andalusia, AL

Prior Authorization Requirements

Criteria for prior authorization approval of Wegovy for adults include:

• A BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related medical condition.
• Meeting eligibility requirements the FDA approved it for.

The Prior Authorization Process

1. Prescription and Pharmacy Notification: Once a healthcare provider prescribes Wegovy, the prescription will be sent to the patient’s preferred pharmacy. If their Blue Cross Blue Shield plan requires prior authorization, the pharmacy will notify the member’s healthcare provider.
2. Healthcare Provider Submission: The healthcare provider will then complete the prior authorization form and submit it to the insurance company.
3. BCBS Review and Decision: It can take up to 10 business days for BCBS to make a final decision.
4. Approval and Coverage: If approved, Wegovy will be covered according to the specifications of the plan, and the pharmacy will dispense the drug.
5. Denial and Alternatives: If denied, BCBS will notify the prescribing healthcare provider. The patient can then choose to pay the full out-of-pocket cost or use an alternate medication prescribed by their healthcare provider.

Cost of Wegovy

Wegovy costs an average of $1,850 for a 28-day supply without insurance or coupons. Costs vary by pharmacy and location, however, so you may pay more or less. If your Blue Cross Blue Shield plan covers Wegovy, the copay can vary depending on the plan. There may be other options to lower the cost of Wegovy, such as using a savings offer from the drug manufacturer or a prescription discount card.

Checking Your Plan Documents

The first step in determining if Wegovy is covered by your plan is to check your plan documents. These should provide information about coverage details and drug formularies, which are the prescription medications your plan covers.

GLP-1 New to Therapy Program

BCBSTX offers an optional pharmacy benefit program called GLP-1 New to Therapy for Administrative Services Only groups with Prime Therapeutics, effective April 1, 2024. This program aims to reduce drug waste and cost associated with beginning GLP-1 drug therapy and helps members utilize the medication as intended, based on FDA labeling, until they find their maintenance dosage.

How it Works

GLP-1 New to Therapy limits initial fills to 30 days for members new to GLP-1 drug therapy.

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Included Drug Products

Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Saxenda, Trulicity, Victoza, Wegovy, and Zepbound.

Program Categories and Medications

The program categories and medications included, as well as any applicable prior authorization programs for GLP-1 and Weight Loss, would be based on the member’s pharmacy benefits.

Important Considerations

Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage, which may vary from the limits set forth above. The listing of any drug or classification of drugs is not a guarantee of benefits.

Optional 30-Day Supply Limit Program

Effective September 1, 2024, an optional 30-day supply limit pharmacy benefit program is available for some employer groups with Prime Therapeutics. This program limits fills to 30 days for all applicable GLP-1 and/or anti-obesity drugs (oral and injectable). The categories and medications included may vary according to employer group selections.

Affected Members

This program is an employer group option that may apply to some commercial members. Always check eligibility and benefits first for each member at every visit.

Drug List Exceptions

If a drug is not on the Drug List or is being removed, you, your prescribing health care provider, or your authorized representative can request a Drug List exception. 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.

BCBSTX and Prime Therapeutics

BCBSTX contracts with Prime Therapeutics to provide pharmacy benefit management and related services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Addressing the Challenge of GLP-1 Utilization

The increasing utilization of GLP-1s has generated the need for ongoing and evolving clinical management strategies and new ways to improve the member experience, such as using data to help qualifying members avoid the prior authorization (PA) process altogether.

Automation at the Pharmacy Counter

Integration of medical claims and prescription claims data are being used in automation logic with network pharmacies. Starting in June 2023, this ‘smart’ automation technology was put in place to review requests for the GLP-1 drugs used for diabetes. Now, when there is a documented medical diagnosis of type 2 diabetes and claims history for diabetes medications, members meet the PA criteria and the prescriber does not need to submit a PA request at all.

Clinical Program Management

Beginning Jan. 1, 2023, the GLP-1 Agonists PA program was added as a standard PA program with dispensing limits to manage appropriate GLP-1 use for patients with type 2 diabetes. Note: some self-insured employers may not have selected this PA program for their members. Prior to the PA program implementation, some drug lists managed these medications under a Step Therapy (ST) program with dispensing limits.

Prescriber Attestation

Effective Nov. 1, 2023: Prescriber attestation of a type 2 diabetes diagnosis is no longer accepted on the PA approval form. Starting on or after Jan 1, 2024, the PA criteria will be updated to remove continuation of therapy for members using a GLP-1 drug but have not gone through the GLP-1 PA program. Members without a type 2 diabetes diagnosis in medical claims or prescription history for other diabetes drugs will work with their prescribers to submit documentation of the missing information to meet prior authorization criteria. However, this does not apply for members with an existing PA in place today for a GLP-1 medicine used for diabetes.

Weight Loss Medications

For employers that have elected to cover weight loss medications, it is important to remember that those drugs are managed independently from diabetic GLP-1 drugs. Weight loss medications have an available weight loss PA program that manages appropriate use of those medicines - including the GLP-1 drugs approved for chronic weight management.

Additional Resources

• MyPrime.com: An online resource offered by Prime Therapeutics.
• Availity: A trademark of Availity, LLC., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.
• Blue365®: Achieve your personal fitness goals on your budget.
• Weight Management Program by Livongo®: Eligible members can get a digital scale and ongoing support to manage their weight and improve their health.

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