Obesity is a significant health concern, and access to effective treatments, including medications like Zepbound, is crucial. Understanding insurance coverage for these medications can be complex. This article aims to provide clarity on Anthem's coverage policies, particularly concerning weight loss drugs like Zepbound.
Understanding Anthem Pharmacy Coverage
Anthem offers pharmacy coverage to its members, with drug lists tailored to specific plans and locations. To access the correct drug list, members should choose the state where their health plan is located. Anthem members with pharmacy coverage can log in to connect automatically to the drug list that applies to their pharmacy benefits. These medications on your drug list are chosen based on a number of factors including how well they work, value to patients and safety.
Specialty Drug Coverage
Some Anthem plans include a PreventiveRx benefit, and specific drug lists apply to these members. Additionally, Anthem provides lists for members who refill prescriptions through home delivery or at an Rx Maintenance 90 pharmacy. It's essential to note that a list of specialty medications, if covered by a member’s plan, are not covered under the pharmacy benefit. Instead, these specialty drugs must be filled through a participating specialty pharmacy for coverage to be provided.
For California members, Anthem Blue Cross offers specific drug lists, including the PreventiveRx Drug List and the Home Delivery and Rx Maintenance 90 Drug List.
Shapely's Partnership with Anthem
Shapely has partnered with Anthem to provide members access to affordable, evidence-based weight loss care. Eligible Anthem PPO members can access personalized medical treatment, lifestyle support, and expert weight loss care covered by their insurance plan.
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What Anthem Covers Through Shapely
As an in-network provider for Anthem, Shapely offers physician-led weight loss care, including medical consultations, lifestyle coaching with a dietitian, and prescriptions for weight loss medication.
Anthem's Coverage of Weight Loss Medications
Anthem coverage for weight loss medications depends on your specific plan. Many plans may cover FDA-approved medications like Wegovy® or Zepbound®, though prior authorization or proof of medical necessity may be required. Shapely helps you navigate the process to make the most of your benefits. If medications aren’t covered, Shapely also offers cost-effective alternatives through compounding pharmacies.
Shapely's Membership Details
Shapely memberships include monthly video visits with an expert weight loss provider, weight loss prescriptions (if appropriate), support getting meds covered by insurance, assistance finding meds at local pharmacies, 1:1 access to a personalized dietitian, and unlimited support via chat and their app. It's important to note that the cost of medication is not included in Shapely memberships.
Shapely offers various membership options, including those for Medicare, commercial insurance, and self-pay. For members choosing to use insurance for their visits with Shapely, insurance covers any visits with our expert team of providers and dietitians, though you may be responsible for any cost-sharing, such as co-pays, deductibles, and co-insurances. In addition, you will still have a membership fee which covers use of our app, chat features with your Shapely team, access to exclusive education, tracking tools, and concierge support.
How Shapely Works
- Sign up online: Tell Shapely about your goals and health history. They'll guide you through insurance or self-pay options with no surprises.
- Meet your provider over video: Connect over video with an expert provider assigned to you - someone who listens and personalizes your care plan to fit your needs.
- Start your treatment: Receive a custom plan that may include medications, lifestyle support, and ongoing follow-up - all designed to help you feel your best.
Medications Prescribed by Shapely
Shapely's medical providers may prescribe several medications, including Semaglutide, Tirzepatide, Wegovy®, Ozempic ®, Zepbound ®, Mounjaro ®, and Contrave®. Prescriptions are at the medical provider’s discretion and may not be appropriate for everyone. Individual results may vary. Average 15% weight loss was seen with Wegovy in Step 1 trial, while average 21% weight loss was seen with Zepbound in Surmount 1 trial, and 6.1% weight loss was seen with Contrave in the COR-1 trial.
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Weight loss medications can help you lose 21% of your body weight when paired with lifestyle change.
Real Patient Results with Shapely
Many patients have experienced significant weight loss and health improvements through Shapely's program:
- Vanessa lost 53 lbs in 9 months and recommends reaching out to the Shapely team to start the journey.
- Kathy lost 42 lbs in 6 months and is no longer on blood pressure medication.
- Tara lost 72 lbs in 12 months, normalized her A1c, and lowered her risk for diabetes and heart disease.
- Mary Jane lost 40 lbs in 5 months and is maintaining her weight loss.
- Jeanine lost 57 lbs in 6 months and has seen a change to everything from her emotional eating to her cravings.
- Cynthia lost 74 lbs in 6 months and reclaimed her health and confidence.
- Patricia lost 36 lbs in 8 months and appreciates the support and encouragement from Dr. Zaghi and Megan.
- Robin lost 85 lbs in 9 months and feels more in control of her weight.
- Laurel lost 56 lbs in 7 months and attributes her success to Shapely shutting off the food noise and cravings.
Eligibility and Insurance Coverage with Shapely
Currently, Shapely serves adults age 18 and older in the states of California, Florida, New York, and Texas. They will soon be expanding to all 50 US states.
Shapely navigates insurance on your behalf and are able to work with the vast majority of insurances to get cost-effective access to GLP-1 medications like Wegovy® and Zepbound®. For patients with commercial insurance, medication co-pays are typically $25 per month, but depending on the plan may be higher. At this time, Medicare only covers these medications for patients with diabetes, cardiovascular disease (such as stroke or heart attack), and obstructive sleep apnea.
If you do not have insurance, or if insurance doesn't cover the cost of medications, Shapely offers an accessibility program and can send your prescriptions to a compounding pharmacy. Labs are also typically covered by insurance though there may be a co-pay. For patients without insurance, Shapely offers labs for a flat-rate of $75, requiring you to go to a Labcorp location for lab draw.
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Lawsuits Against Insurance Companies for Denying Weight Loss Drug Claims
It’s important to note that there is increasing legal pressure on insurance companies to cover weight loss drugs. For instance, a lawsuit was filed in Maine against an insurance company for denying claims for weight loss drugs. Zepbound, for example, is a weekly injection that can cost more than $1,000 a month for patients who pay out of pocket. According to the lawsuit, the “obesity exclusion is irrational, arbitrary and likely more expensive than covering prescription medications for obesity.”