Unlock the Secrets to BCBSTX Weight Loss Medication Coverage – Your Ultimate Guide!

Navigating insurance coverage for weight loss medications can be complex. This article provides a detailed overview of Blue Cross Blue Shield of Texas (BCBSTX) coverage for weight loss medications, particularly focusing on GLP-1 drugs like Wegovy, Ozempic, and Mounjaro. This guide incorporates recent updates and programs to help you understand your options and potential costs.

BCBSTX and Pharmacy Benefit Management

Blue Cross Blue Shield of Texas (BCBSTX) partners with Prime Therapeutics, a pharmacy benefit management company, to manage pharmacy benefits and related services. It's important to note that BCBSTX, along with other independent Blue Cross and Blue Shield Plans, holds an ownership interest in Prime Therapeutics LLC.

Optional Pharmacy Benefit Programs

GLP-1 New to Therapy Program

As of April 1, 2024, BCBSTX offers a new optional pharmacy benefit program called GLP-1 New to Therapy for Administrative Services Only groups with Prime Therapeutics. This program aims to reduce drug waste and costs associated with starting GLP-1 drug therapy and help members use 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.
Drug products that can be included are Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Saxenda, Trulicity, Victoza, Wegovy, and Zepbound.
The program categories, medications included, and any applicable prior authorization programs for GLP-1 and Weight Loss are based on the member’s pharmacy benefits.

30-Day Supply Limit Program

Starting 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. 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.

Coverage for Wegovy

Blue Cross Blue Shield (BCBS) may cover the cost of Wegovy, a brand-name medication approved by the FDA for weight loss in certain patients, including children 12 years and older, and to reduce cardiovascular risk in adults with obesity or who are overweight. However, coverage depends on your specific insurance plan, BMI, and weight-related health conditions, and it often requires prior authorization.

Read also: Weight Loss Guide Andalusia, AL

Prior Authorization Criteria:

To meet the Wegovy pre-authorization criteria, patients will have to meet the eligibility requirements the FDA approved it for. Criteria for prior authorization approval of Wegovy for adults may include:

A BMI of 30 or higher.
A BMI of 27 or higher with at least one weight-related medical condition.

Prior authorization approval can expire, requiring reapproval.

The Prior Authorization Process:

Prescription: Once a healthcare provider prescribes Wegovy, the prescription will be sent to the patient’s preferred pharmacy.
Notification: If the Blue Cross Blue Shield plan requires prior authorization, the pharmacy will notify the member’s healthcare provider.
Form Completion: The healthcare provider will complete the prior authorization form and submit it to the insurance company.
Review: It can take up to 10 business days for BCBS to make a final decision.
Approval: If approved, Wegovy will be covered according to the specifications of the plan, and the pharmacy will dispense the drug.
Denial: 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.

The Blue Cross Blue Shield prior authorization form for Wegovy will vary by plan. Typically, the form may ask for your contact information, date of birth, prescriber’s information, the diagnosis for Wegovy (reason for taking it), and the dosage prescribed by your healthcare provider. The prior authorization form will also ask questions that help the plan determine if you meet its criteria for approval.

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.

Ways to Lower the Cost:

Savings Offers: Use a savings offer from the drug manufacturer.
Prescription Discount Card: Use a prescription discount card. For example, SingleCare offers a free Wegovy coupon that can help you save, depending on your location and pharmacy.

To find the most accurate price, enter the correct dosage and quantity for your Wegovy prescription on the SingleCare coupon page. Then, choose the coupon for your preferred pharmacy.

Checking Your BCBSTX Plan for Coverage

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. To find out if a prescription drug is covered by your plan, it's best to log in to your member account and click on the Pharmacy tab.

Drug List Exceptions

You, your prescribing health care provider, or your authorized representative, can ask for a Drug List exception if your drug is not on (or is being removed from) the Drug List. 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.

BCBSTX's Approach to GLP-1 Coverage

Blue Cross and Blue Shield of Texas focuses on ensuring coverage and minimizing barriers for patients with type 2 diabetes, while also supporting weight loss coverage as a custom benefit option. This allows groups to make decisions that best align with their strategy.

Read also: Inspiring Health Transformation

The rise in 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 January 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.

Effective November 1, 2023, prescriber attestation of a type 2 diabetes diagnosis is no longer accepted on the PA approval form.

Starting on or after January 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.

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.

Challenges in GLP-1 Coverage

Some Blue Cross Blue Shield plans are starting to limit or exclude coverage for weight loss drugs like Ozempic and Wegovy due to skyrocketing costs. For example, Blue Cross Blue Shield of Massachusetts announced that starting January 1, 2026, standard coverage plans will not cover GLP-1s for weight loss, though they will continue to cover patients using the drugs for diabetes treatment.

The increasing demand for GLP-1s has led to higher prices, creating an "unsustainable burden" on employers and members. In 2024, five GLP-1 drug companies accounted for 20% of their total pharmacy spend, which topped $300 million the previous year. This has prompted calls for insurers to negotiate more aggressively with pharmaceutical companies.

Alternative Options and Resources

Curex

Curex offers comprehensive care for those suffering from allergies, asthma, and eczema, including customized sublingual immunotherapy, at-home concierge allergy testing, and symptom management. They also offer weight management programs. Their plans cover reviewing your medical intake to providing prescription medications, with free shipping included.

If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide. These compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness.

Curex does not require insurance, offering clear and simple pricing, along with affordable medication options. You can pay with your HSA or FSA card.

MedsYourWay

MedsYourWay is a drug discount card program that compares the drug discount card price for an eligible medication at participating pharmacies to the member’s benefit plan cost share amount and then applies the lower available price. Eligible medications are subject to change, prescription prices may vary by location and not all pharmacies participate.

Patient Assistance Programs

Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs.

Important Considerations

Independent Medical Judgment: The information provided here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment.
Certificate of Coverage: 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.
Guarantee of Benefits: The listing of any drug or classification of drugs is not a guarantee of benefits.
Eligibility and Benefits: Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered.
Final Decision: Regardless of benefits, the final decision about any medication is between the member and their health care provider.

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