The increasing popularity of GLP-1 agonists like Wegovy for weight loss has led to many questions regarding insurance coverage. This article aims to provide clarity on Fidelis Care's coverage policies, particularly concerning Wegovy and other GLP-1 agonists, and guide you through the process of determining your eligibility and exploring available options.
Understanding Fidelis Care's Stance on GLP-1 Agonists
Fidelis Care has observed a surge in requests for GLP-1 agonists, especially Ozempic and Mounjaro. These medications are primarily FDA-approved for treating type 2 diabetes. The increasing use of these drugs for weight loss has led to shortages for diabetic patients. As a result, Fidelis Care actively monitors prior authorization (PA) requests to ensure these medications are prescribed according to FDA-approved indications. The need for documentation to support attestations made during the PA request process may arise.
It's important to note that coverage for products specifically indicated for weight loss may vary depending on your specific plan. For detailed information, it is recommended to visit the Pharmacy Services webpage on the Fidelis Care website.
Checking Your Wegovy Coverage with Novo Nordisk
Novo Nordisk, the maker of Wegovy, offers a platform to check your insurance coverage and explore potential savings offers. You can access this platform and answer questions to determine your coverage status.
To get started, you'll need to indicate whether you're a patient or caregiver and provide your insurance details. You'll also be required to enter personal information such as your name, date of birth, gender, and zip code. After reviewing the information for accuracy and consenting to the terms, you can proceed to enter your healthcare professional's details, including their first and last name, city, and state. This information is crucial for verifying the prescription and facilitating the prior authorization process if needed.
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Based on your submitted answers, the platform will indicate whether your insurance plan covers Wegovy. If coverage is not provided or immediate details are unavailable, the platform may offer alternative options to explore.
Interpreting Coverage Messages and Taking Action
The platform provides different messages based on your coverage status. If your insurance requires prior authorization, your healthcare professional will need to complete a prior authorization form and submit it to the insurance company. The insurer will then assess the form to determine coverage eligibility and communicate the decision to you and your healthcare professional.
If your result indicates that Wegovy is not covered, you have the option to submit an appeal or request for coverage with the assistance of your healthcare professional. In some cases, the coverage result may be undetermined, indicating that more information is needed to process your request.
If you have commercial insurance and your plan covers Wegovy (either with or without prior authorization), discuss with your healthcare professional whether Wegovy is a suitable option for you. You may also be eligible for the Wegovy savings card, which can help reduce out-of-pocket expenses. Keep in mind that government-insured patients are not eligible for manufacturer copay cards.
Leveraging the Formulary and Exploring Exceptions
A drug formulary lists generic and brand-name prescription drugs covered by your prescription drug benefit. Wellcare By Fidelis Care actively manages and updates the formulary through its Pharmacy and Therapeutics Committee, comprised of qualified pharmacists and doctors focused on providing safe, high-quality, and cost-effective drugs.
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You can potentially lower your monthly prescription drug costs by switching to a preferred drug listed on the formulary. If you are currently taking a brand-name drug, consider switching to a generic alternative when available, as this can significantly reduce your out-of-pocket expenses. Additionally, obtaining up to a 100-day supply of your medication may be more cost-effective than purchasing three 30-day supplies at a retail pharmacy.
If a drug is not covered as desired, you can request an "exception," which is a type of coverage decision. To request a formulary exception (coverage for a drug not on the formulary), your doctor must provide medical reasons supporting the need for the exception. Fidelis Care will then review your request.
Understanding Drug Tiers and Generic Substitution
The price of a drug is determined by its "tier" within the formulary. Preferred tier drugs are typically less expensive than non-preferred tier drugs. Discussing preferred tier options with your primary care physician can help reduce your prescription drug costs.
Wellcare By Fidelis Care may generically substitute medications when an authorized, AB-rated generic equivalent is available, unless the prior authorization or exception request specifically indicates that the brand name is required.
Navigating Formulary Transitions and Pharmacy Networks
If you are taking a drug that is not on the formulary or has limited availability, Fidelis Care will provide a temporary supply to allow you to switch to a covered drug or request a formulary exception.
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Fidelis Care maintains a pharmacy network that meets or exceeds CMS requirements for pharmacy access in your area.
Requesting Coverage for Non-Formulary Medications
If a medication is not on your plan's drug list or is restricted, you can request coverage by completing a medication request form. This form provides the plan with the necessary information to determine whether to waive the restriction. However, approval is not guaranteed.
Additional Resources and Support
Wellcare By Fidelis Care offers a member portal to ensure access to affordable medication and convenient prescription filling options. You can also apply for the "Extra Help" benefit (Low Income Subsidy Assistance) to assist with prescription drug costs. Fidelis Care also offers members a prepaid account to purchase over-the-counter drugs and health-related items at local pharmacies through the Wellcare Spendables card.
Addressing the Rise in GLP-1 Agonist Demand
The increased awareness of GLP-1 agonists as a weight loss solution on social media has led to a surge in demand. Semaglutide and liraglutide are examples of GLP-1 agonist medications with formulations approved for both type 2 diabetes and weight loss. It's important to ensure that these medications are used appropriately and as indicated.