The landscape of weight loss medication coverage is shifting, particularly concerning glucagon-like peptide-1 (GLP-1) agonists like Ozempic and Wegovy. These drugs, initially developed for diabetes treatment, have gained immense popularity for their weight loss effects, leading to both soaring sales and concerns about unsustainable costs for insurers and healthcare systems. Blue Cross Blue Shield (BCBS), a major health insurance provider, is at the forefront of this changing landscape, re-evaluating its coverage policies in response to the growing financial strain.
The Rise of GLP-1s and Their Impact
GLP-1 drugs have become increasingly common, with studies suggesting that nearly one in eight people have used them. This surge in popularity has prompted drug companies to increase prices, placing a significant financial burden on insurers like Blue Cross Blue Shield. In 2024, five GLP-1 drug companies accounted for 20% of BCBS's total pharmacy spend, which exceeded $300 million-double the amount from the previous year.
Blue Cross Blue Shield's Coverage Adjustments
Several Blue Cross Blue Shield companies are making adjustments to their coverage of GLP-1 drugs for weight loss.
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Massachusetts announced that, starting January 1, 2026, standard coverage plans will no longer cover GLP-1s for weight loss. However, the company will continue to cover patients using these drugs for diabetes treatment.
Federal Employee Program (FEP)
Beginning January 1, 2025, the tiers for some weight loss GLP-1 drugs will change for members with FEP Blue Standard® and FEP Blue Basic® plans.
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Financial Strain and Sustainability Concerns
The increasing costs associated with GLP-1 drugs have raised concerns about the sustainability of current coverage models. Ruby Kam, CFO of Blue Cross Blue Shield, noted that the rapid escalation of medical care and medication costs is placing a heavy and unsustainable burden on employer customers and members. This financial strain is forcing insurers to make difficult decisions about coverage.
The Massachusetts Group Insurance Commission (GIC), which provides insurance to state employees and their families, is also facing budget challenges due to the rising costs of GLP-1 drugs. The GIC has requested an additional $240 million from the Legislature to cover these costs.
Industry Perspectives
Jon Hurst, president of the Retailers Association of Massachusetts, emphasized the need for insurers to negotiate with pharmaceutical companies to address the high costs of these drugs. He pointed out that mandated coverage at high reimbursement rates is directly impacting businesses' bottom lines, particularly small businesses facing double-digit premium increases.
Factors Influencing Coverage Decisions
Several factors influence Blue Cross Blue Shield's coverage decisions regarding weight loss medications:
BMI and Weight-Related Health Conditions: Coverage for drugs like Wegovy may depend on a patient's Body Mass Index (BMI) and the presence of weight-related health conditions.
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Prior Authorization: Many BCBS plans require prior authorization before covering weight loss medications like Wegovy.
Plan-Specific Coverage: Coverage varies by plan, and some policies may not cover weight loss medications at all. Members are advised to check with their insurance company or employer to verify their plan's coverage.
Alternatives and Cost-Saving Measures
For individuals whose insurance plans do not cover Wegovy or other weight loss medications, several alternatives and cost-saving measures are available:
SingleCare Discount Card or Coupon: Consider using a SingleCare discount card or coupon to reduce the cost of Wegovy.
Manufacturer Coupons: Explore manufacturer coupons, such as those offered by Novo Nordisk for Wegovy.
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Alternative Medications: Discuss alternative prescription weight loss medications, like Saxenda, with a healthcare provider, as some plans may cover these even if they don't cover Wegovy.
Off-Label Use: Some medications, like Mounjaro, are approved for managing blood sugar levels in adults with Type 2 diabetes but may be prescribed off-label for weight loss.
Accessing Information and Support
Blue Cross Blue Shield offers several resources to help members understand their coverage and access support for weight management:
Online Formulary: Members can search the formulary on Prime Therapeutics to see if their medication is covered.
Prior Authorization Forms: If required, members can ask their prescriber to complete the Prior Authorization/Medical Necessity Determination form found on the Forms page of Prime Therapeutics.
Weight Management Programs: Eligible members can access programs like the Weight Management Program by Livongo®, which provides a digital scale and ongoing support.
Blue365®: This program offers deals on health and wellness brands to help members achieve their fitness goals.
Registered Dieticians: Members can connect with registered dieticians for personalized meal plans and nutritional support.
The Importance of Lifestyle Changes
While weight loss medications can be effective, they are often most successful when combined with lifestyle changes such as improved nutrition and increased physical activity. Blue Cross Blue Shield provides resources and support to help members make these changes.
Concerns about Discontinuation and Long-Term Benefits
Despite the effectiveness of GLP-1 drugs, a significant number of patients discontinue use before experiencing clinically meaningful health benefits. A study by Blue Cross Blue Shield Association (BCBSA) found that 58% of patients discontinue use before reaching a clinically meaningful health benefit. Factors such as cost, transportation, language barriers, and lack of specialist care can contribute to discontinuation.
Blue Cross Blue Shield's Commitment to Addressing Obesity
Blue Cross Blue Shield recognizes the importance of addressing obesity, with an estimated one in three American adults being obese. The company offers various programs and resources to support members in their weight management efforts, including personalized action plans and coverage for weight-loss drug prescriptions for eligible members who meet specific criteria and obtain prior approval. FEP also covers procedures to treat morbid obesity with prior approval.