Blue Cross and Blue Shield of Illinois (BCBSIL) offers various pharmacy benefit programs, including coverage for weight loss medications. These programs are subject to change and vary based on employer group selections and individual member plans. It's crucial to understand the specifics of your coverage to make informed decisions about your health.
Pharmacy Benefit Management and Prime Therapeutics
BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSIL, as well as other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC. MyPrime.com is an online resource offered by Prime Therapeutics. Prime Therapeutics LLC is a pharmacy benefit management company.
Optional 30-Day Supply Limit Program
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. This program is an employer group option that may apply to some of our commercial members. Always check eligibility and benefits first for each member at every visit.
GLP-1 New to Therapy Program
As of April 1, 2024, an optional GLP-1 New to Therapy pharmacy benefit program became available for some employer groups with Prime Therapeutics. This new program aims to reduce drug waste and cost of care associated with beginning GLP-1 drug therapy. The program limits initial fill(s) to 30 days for members who are new to GLP-1 drug therapy or have no claims history within the past 120 days. After the initial fill(s), members may be eligible for up to a 90-day supply, per their pharmacy benefits. The 30-day supply limit may continue to apply after the first fill if the member moves to a new dosing strength or changes to a different GLP-1 medication. GLP-1 New to Therapy categories and medications included may vary according to employer group selections. This program is one example of an employer group option that may apply to some of our commercial members. Always check eligibility and benefits first for each member at every visit.
GLP-1 Agonists and Weight Loss
Glucagon-like peptide-1 agonists (GLP-1) are a class of medications approved to help improve blood sugar control for people who have type 2 diabetes. In addition to the positive effects on diabetes, this category of drugs also results in weight loss. When weight loss success stories were shared on social media, there was a surge in demand and use, not only from people that have type 2 diabetes, but also those seeking weight loss.
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Ensuring Coverage and Minimizing Barriers
Blue Cross and Blue Shield of Illinois has continued to focus 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 decision that best align with their strategy. The continued 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. This data connects medical diagnoses with prescription claims at the time of processing to qualify members who meet clinical‑program criteria and remove them from any prior authorization review requirements. 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. 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. All approved PAs will remain in effect until the expiration date, and our PA notification alerts will remind members and prescribers about those dates in advance. 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. 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. BCBSIL continues to monitor market changes and medication utilization.
Important Considerations Regarding 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. 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. You also can review other materials about covered medications. Drugs on your drug list are chosen based on their safety, cost and how well they work. While doctors are encouraged to prescribe drugs on the list, treatment decisions are between you and your doctor. If you know which drug list your plan uses, access it below.
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Requesting a Drug List Exception
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.
Prior Authorization Program
The pharmacy prior authorization program encourages safe, cost‑effective medication use by allowing coverage when certain conditions are met. Treatment decisions are always between you and your patients. Coverage is subject to the terms and limits of your patients’ benefit plans. If your patients have any questions about their pharmacy benefits, they can contact the number on their member ID card. Prime Therapeutics LLC is a separate company contracted by Blue Cross and Blue Shield of Illinois to provide pharmacy solutions. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
Additional Ways to Save on Prescriptions
Prescriptions can be expensive. You may be able to save on your drug or pharmacy costs. Speak with your doctor about submitting an authorization request. MedsYourWay automatically applies drug discount card prices on eligible prescriptions. You may have lower-cost alternatives for your prescription, like generic drugs. At a preferred pharmacy, you may pay the lowest copay or coinsurance. Some prescriptions can be filled in a larger amount, just like you would buy in bulk from a grocery store. 1 Coverage is based on the terms and limits of your plan. For some drugs, you must meet certain criteria before prescription drug coverage may be approved. Commonly used drugs that are no longer covered may not apply to all strengths/formulations. Food and Drug Administration approval are not covered. Some benefit plans may have preventive drug benefits. This means you may pay a lower cost, as low as $0, for preventive care drugs. If your plan has preventive drug benefits, and coverage for your prescription changes, the amount you pay under the preventive drug benefit may also change. 3 MedsYourWay is not insurance. It 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. 5 Not all prescriptions can be filled in a 90-day supply and may need to be filled at select retail pharmacies or via home delivery.
Summary of Benefits and Coverage (SBCs)
These short, easy-to-understand Summary of Benefits and Coverage (SBCs) include a new, standardized plan comparison tool called "coverage examples", like the Nutrition Facts label required for packaged foods. The coverage examples will illustrate sample medical situations and describe how much coverage the plan would provide in an event such as having a baby (normal delivery) or managing Type 2 diabetes (routine maintenance, well-controlled). The Glossary of Health Coverage and Medical Terms will assist you with determining the benefits of each plan.
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Important Disclaimers
The information mentioned 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. 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 particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.
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