The increasing demand for weight loss medications, particularly glucagon-like peptide-1 (GLP-1) agonists, has created both opportunities and challenges for insurers and patients alike. Blue Cross and Blue Shield of Illinois (BCBSIL) is working to balance providing coverage for these medications with managing their appropriate use and costs. This article explores BCBSIL's approach to weight loss medication coverage, including recent changes to prior authorization (PA) processes and strategies for ensuring members have access to the medications they need.
The Rise of GLP-1 Agonists
Glucagon-like peptide-1 agonists (GLP-1) are a class of medications initially approved for improving blood sugar control in individuals with type 2 diabetes. A significant side effect of these drugs is weight loss, leading to increased demand from both diabetic and non-diabetic individuals seeking weight management solutions. Social media has further amplified the demand for these medications.
BCBSIL's Coverage Strategy
Blue Cross and Blue Shield of Illinois has focused 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. BCBSIL's strategy involves:
- Ensuring coverage for patients with type 2 diabetes.
- Supporting weight loss coverage as a custom benefit option for employer groups.
- Implementing clinical management strategies to manage the increasing utilization of GLP-1s.
- Improving the member experience through data-driven automation.
Automation at the Pharmacy Counter
BCBSIL is leveraging data to streamline the prior authorization process for GLP-1 drugs used for diabetes. By integrating medical and prescription claims data, the system can automatically identify members who meet clinical program criteria.
Starting in June 2023, BCBSIL implemented "smart" automation technology to review requests for GLP-1 drugs used for diabetes. This system connects medical diagnoses with prescription claims at the time of processing. When a member has a documented diagnosis of type 2 diabetes and a claims history for diabetes medications, the system automatically approves the PA request, eliminating the need for the prescriber to submit a PA form.
Read also: Weight Loss Meds & BCBS
Clinical Program Management
To manage the appropriate use of GLP-1 agonists for patients with type 2 diabetes, BCBSIL implemented a standard PA program with dispensing limits on January 1, 2023. However, it's important to note that some self-insured employers may not have selected this PA program for their members. Before this program, some drug lists managed these medications under a Step Therapy (ST) program with dispensing limits.
Recent and Upcoming Changes to the GLP-1 Agonists PA Program
BCBSIL is making the following changes to the GLP-1 Agonists PA program:
- 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 who 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 need to work with their prescribers to submit documentation of the missing information to meet prior authorization criteria.
These changes do not apply to members with an existing PA in place for a GLP-1 medicine used for diabetes. All approved PAs will remain in effect until the expiration date, and PA notification alerts will remind members and prescribers about those dates in advance.
Weight Loss Medication Coverage
For employers who have elected to cover weight loss medications, BCBSIL manages these drugs independently from diabetic GLP-1 drugs. Weight loss medications have a separate weight loss PA program that manages the appropriate use of these medicines, including the GLP-1 drugs approved for chronic weight management. It's important to note that the changes to the type 2 diabetes GLP-1 PA program are not connected to any weight loss drug coverage an employer may also have in place.
Finding Information About Your Specific Plan
To find out if a prescription drug is covered by your plan, it's best to log into your member account and click on the Pharmacy tab.
Read also: Managing a Blue Spa: Key Responsibilities
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 BCBSIL 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. BCBSIL 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, BCBSIL 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. BCBSIL 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, BCBSIL 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.
Important Considerations Regarding Wegovy
Wegovy is generally prescribed for chronic weight management and may be covered if there is documented obesity or a BMI of 30 or higher.
Semaglutide (Wegovy) FAQ
Clinical trials demonstrate that Semaglutide (Wegovy) helps individuals lose a significant amount of weight. Results vary, with some losing more and others less.
Read also: Understanding BCBS Weight Loss Benefits
Wegovy is primarily for weight management in adults with obesity. While both are weekly injections, Wegovy generally has higher dosing than Ozempic (up to 2.4mg vs. Though similar, they serve distinct medical purposes.
Wegovy Side Effects and Precautions
- Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Wegovy® and medicines that work like Wegovy® caused thyroid tumors, including thyroid cancer.
- Wegovy® may harm your unborn baby.
- Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Wegovy® may affect the way some medicines work and some medicines may affect the way Wegovy® works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin.
- Inflammation of your pancreas (pancreatitis). Stop using Wegovy® and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting.
- Gallbladder problems. Wegovy® may cause gallbladder problems, including gallstones. Some gallstones may need surgery.
- Increased risk of low blood sugar (hypoglycemia), especially those who also take medicines for diabetes such as insulin or sulfonylureas. This can be a serious side effect. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Wegovy®.
- Kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse.
- Severe stomach problems. Stomach problems, sometimes severe, have been reported in people who use Wegovy®.
- Serious allergic reactions.
- Change in vision in people with type 2 diabetes.
- Increased heart rate. Wegovy® can increase your heart rate while you are at rest.
- Depression or thoughts of suicide. You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings.
- Food or liquid getting into the lungs during surgery or other procedures that use anesthesia or deep sleepiness (deep sedation). Wegovy® may increase the chance of food getting into your lungs during surgery or other procedures.
The Broader Context of Weight Loss Medications
The use of medications like Wegovy is not without controversy. They are approved for diabetes, and for people with obesity who also have weight-related conditions such as high blood pressure or high cholesterol that put them at risk of heart disease. But, the drugs aren't intended for cosmetic weight loss. There's been such an increase in demand that an FDA database lists the medication's active ingredient, semaglutide, as "currently in shortage."
At a cost of about $1,400 a month - out of pocket when insurance doesn't cover it - many people can't afford to stay on the medication for the long term. And when people stop taking it, there's often rebound weight gain that's hard to control.
The rebound weight gain is not a surprise given how the medication works. Wegovy's active ingredient - semaglutide - is a GLP-1, or glucagon-like peptide-1, which mimics the GLP-1 satiety hormone in our bodies. "This hormone is telling your brain, I'm full, I don't need to eat anymore," explains Dr. Robert Kushner of Northwestern University. "What the pharmaceutical companies have done is taken this hormone that is naturally occurring and restructured it into a drug," he explains.
Since Wegovy was approved by the FDA in 2021, some insurance plans have begun to cover the medication for people who meet the clinical prescribing guidelines. According to the FDA, people are eligible if they have a BMI of 27 or higher and also have at least one "weight-related ailment" such as hypertension, diabetes, or high cholesterol. But insurance coverage is very spotty. Medicare does not cover Wegovy or other weight loss drugs, and many insurers follow Medicare's lead.
The fact that people may need to stay on Wegovy indefinitely in order to maintain the weight loss has raised concerns about long-term use. The most common side effects of the drug are GI symptoms. He says starting with a low dose and increasing it over time can help people tolerate the drug better. But the drug does carry a black box warning because in rodent studies it caused thyroid tumors. So, Kushner says doctors need to screen patients to find out if they have a family history of a specific kind of thyroid carcinoma, or another rare condition called multiple endocrine neoplasia syndrome type 2 (MEN 2). "This would be an individual patient conversation," Kushner says.
Alternative Approaches to Weight Management
Of course, exercise and diet modification are still the first strategies to try. "We, as a society, are spending $173 billion in obesity-related health care costs," says Dr. He argues that the drugs can be part of destigmatizing obesity by treating it like any other disease that you treat with medicine. "We would not ask someone who has hypertension to just do exercises and change your diet and then you will be fine. No, we give them beta blockers. It's not different here. Exercise and diet are key components of tackling obesity, but so are medications which have proven to be effective," he says.
Additional Programs and Considerations
Starting Sept. 1, 2024, an optional 30-Day supply limit pharmacy benefit program is available for some employer groups with Prime Therapeutics. The program limits fills to 30 days of all applicable GLP-1 and/or anti-obesity drugs (oral and injectable), depending on the member’s pharmacy benefits. The categories and medications included may vary according to employer group selections.
A GLP-1 New to Therapy program became available April 1, 2024, for some employer groups with Prime Therapeutics, as an optional pharmacy benefit program for members beginning GLP-1 therapy.
Curex and Allergy Treatment
Curex provides comprehensive care for those suffering from allergies, asthma and eczema. This includes customized sublingual immunotherapy, at-home concierge allergy testing, and symptom management.
Curex currently treats allergies to food, tree, weed, grass pollens, pet allergies, dust mites, mold and cockroach. We do not treat metal, or venom allergies.
Treatments are shipped in 3 month installments in all plans. Cancellations are accepted prior to the next refill being compounded by the pharmacy (so you can get a partial refund on a prepayment plan). The solution is gluten-free.
Prime Therapeutics and BCBSIL
Blue Cross and Blue Shield of Illinois contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.