In a society grappling with rising obesity rates, maintaining a healthy weight has become a paramount concern for many individuals. While conventional methods like diet and exercise yield success for some, others find themselves seeking additional support. Prescription weight loss medications have emerged as a potential avenue for those struggling to shed excess pounds. Blue Cross Blue Shield (BCBS) of Louisiana acknowledges the significance of addressing overweight and obesity and offers coverage for certain weight loss medications, such as Wegovy and Saxenda, contingent upon meeting specific plan eligibility criteria.
Navigating Prescription Drug Benefits with Blue Cross Blue Shield
Your prescription drug benefit is based on a list of covered drugs called a formulary. A group of independent doctors and pharmacists chooses the drugs for our formularies based on their effectiveness, safety and value. Different formularies may cover different drugs, place drugs at different copayment tiers or have different management programs. Each drug in the formulary is assigned a tier under your benefit plan. Each tier is associated with a copayment or coinsurance amount. This is the amount you pay when you get a prescription.
Understanding Formularies and Drug Tiers
- Formulary: A formulary is a list of prescription drugs covered by your insurance plan. The drugs on the formulary are selected by a committee of independent doctors and pharmacists based on their effectiveness, safety, and value.
- Drug Tiers: Each drug on the formulary is assigned to a specific tier, which determines the amount you will pay out-of-pocket. Typically, lower tiers have lower copayments or coinsurance, while higher tiers have higher costs.
Factors Affecting Coverage
It's important to note that coverage for weight loss medications can vary based on your specific plan. Some plans may exclude coverage for certain categories of drugs, such as those for weight loss, fertility, or sexual dysfunction. However, you and your doctor always have the freedom to choose the medication that works best for you.
From time to time, our pharmacy committee may decide to no longer cover some drugs. The committee does this when other safe, effective, less costly alternatives are available. Those drugs are then moved to nonformulary status.
Accessing Preventive Medications
The Affordable Care Act (ACA) requires most health plans to cover certain preventive drugs at $0 cost to members. Taking preventive drugs, as directed by your doctor, may help you live a healthier life today and avoid serious illness in the future. Additionally, IRS guidelines for high-deductible health plans provide that preventive care, including prescription medications used for preventive purposes, can be excluded from the deductible.
Read also: Weight Loss Guide Andalusia, AL
Generic vs. Brand-Name Drugs
Generic drugs become available when patents expire on brand-name drugs. They contain the same active ingredients as brand-name drugs but are not manufactured under a brand name or trademark. The color and shape of the generic drug may be different from its brand-name counterpart, but the active ingredients are the same for both. Some members have a Dispense as Written generic program as part of their prescription drug benefit. This means if a member has a prescription for a particular brand-name drug that is also available in generic form, he or she will pay more for that brand-name drug if he or she opts to fill it instead of the generic version.
Medication Adherence Program
The treatment of chronic illnesses often requires the long-term use of prescription drugs. While these long-term, or maintenance, medications are effective in combating disease, many patients don’t get their full benefits because they don’t take their medications as prescribed. Proper use of prescription drugs is called medication adherence. If your plan includes the medication adherence program, you may get letters or phone calls if we note that you haven’t been keeping up with taking your medication.
Blue Cross Blue Shield Federal Coverage Criteria for Weight Loss Medications
Before seeking coverage for weight loss medication, it's crucial to understand the criteria BCBS uses for approval. BCBS may approve coverage for medications like Semaglutide (Wegovy) and Saxenda if you have a Body Mass Index (BMI) of 30 or higher.
BMI and Associated Health Conditions
Increased BMI alone might not guarantee insurance coverage. However, if you have a BMI of 27 or higher and suffer from at least one health condition associated with obesity, such as cardiovascular disease (CVD), hypertension, type 2 diabetes, obstructive sleep apnea, or impaired glucose tolerance, you may be eligible for coverage for both the underlying illness and the excess weight.
Lifestyle Modification Requirements
BCBS typically requires members to demonstrate a commitment to lifestyle changes through exercise and diet before considering coverage for weight loss medications like Contrave, Saxenda, Qsymia, Wegovy, or Xenical. This often involves a minimum of six months of documented attempts at lifestyle modification under the guidance of a healthcare professional.
Read also: Beef jerky: A high-protein option for shedding pounds?
The insurance wants its members to be engaged in diet, exercise, or even a weight-loss program like Weight Watchers or Noom under a healthcare professional’s guidance.
Verifying Your Benefits and Meeting Requirements
While it's recommended to verify your benefits with BCBS directly, it's also a good idea to call Blue Cross Blue Shield directly to inquire about your plan’s coverage and criteria. You can also read the coverage documentation your employer or insurance gave you.
Once you've confirmed that your plan covers weight loss medication, it's essential to understand the specific requirements. Each plan has a unique set of standards and conditions that must be met to establish medical necessity to the insurance's satisfaction.
Consultation and Documentation
Once your benefits have been verified, you’ll meet with our healthcare practitioner for consultation. They will document your height, weight, BMI, comorbid conditions, and tried and unsuccessful attempts to lose weight through lifestyle changes alone.
If your plan requires it, you may need to begin visiting a dietician for a medically supervised weight loss program. Appointments are typically monthly throughout the life of the plan.
Read also: Inspiring Health Transformation
The Authorization Process
Once all insurance requirements are met, the authorization process begins. Relevant medical records are collected and submitted to the BCBS clinical review section.
A determination may take up to four weeks, but it usually only takes two weeks. We will inform you about the acceptance or denial as soon as we hear from the insurance company. If you’re approved, your weight loss treatment can start.
If you're not approved, the decision will be reviewed, and a follow-up with the insurance company will be initiated.
Ensuring Approval for Weight Loss Medication Coverage
To increase your likelihood of approval for weight loss medication coverage, it's crucial to maintain complete compliance with the standards outlined in the medical policy.
Patient Health History and Documentation
Completing the patient health history questionnaire honestly is essential, as this information will be translated into your medical record, which BCBS will review.
If you have any documentation, including medical chart notes, diaries, personal records, or receipts, of your prior attempts at weight loss, whether by exercise, diet, or medical supervision, bring a copy to be examined and scanned into your chart.
If you've undergone previous weight-loss treatment, obtain copies of your report to demonstrate diligent follow-up and adherence to any advice provided by your previous practitioner.
Medical Supervision and Compliance
Diets under medical supervision should be spaced for about 30 days and frequently need to occur for several months. Failure to follow visits in consecutive calendar months will frequently lead to denial, delay your treatment, or require you to restart the recommended program from scratch.
Overview of FDA-Approved Weight Loss Medications
The Food and Drug Administration (FDA) has approved several medications to assist individuals who are overweight or obese in losing weight. These medications require a doctor's prescription and should be taken under medical supervision.
Types of Weight Loss Medications
- GLP-1 agonists, including liraglutide (Saxenda) and semaglutide (Wegovy)
- phentermine/Topiramate (Qsymia)
- setmelanotide (Imcivree)
- orlistat (Xenical)
- naltrexone/bupropion (Contrave)
How Weight Loss Medications Work
Most of these drugs work by one or more of the following mechanisms:
- Decreasing appetite
- Increasing fullness and causing you to consume fewer calories.
- Limiting the absorption of nutrients like fat, which causes you to consume fewer calories
- Enhancing fat burning, boosting the burning of calories.
Weight loss medications may be an efficient means of reducing your weight when combined with other lifestyle modifications and taken under the guidance of a healthcare practitioner.
Most of these drugs are verified to be used by adults with obesity or overweight with at least one illness associated with weight, such as high blood pressure, type 2 diabetes, or high cholesterol.
These medications are made for those who have tried diets and other lifestyle changes without success in losing weight.
While they shouldn't be used as a quick fix, when combined with regular exercise and a healthy diet, these drugs can be a helpful tool to promote weight management.
Remember that not everyone is eligible for weight-loss drugs, including pregnant women, people with certain medical conditions, or on particular medications.
Addressing Insurance Denials and Exploring Alternatives
If BCBS denies coverage for your weight loss medication, explore alternative options for more affordable coverage. Unfortunately, medications like WeGovy and Ozempic will typically still cost $700 or more.
Alternative Strategies for Weight Loss
If you simply can't afford weight loss medication. The right supplements and dietary modifications might help you achieve your weight loss and health goals.
You can also reduce cravings by switching to an eating pattern that doesn’t cause your blood sugar to rise excessively, which is one of the primary benefits of weight loss medication.
The best approach to ensure your success, whether or not you take medication, is working with a healthcare professional familiar with the science behind efficient weight loss.
Additional Resources and Discounts
Blue Cross and Blue Shield of Louisiana members get perks that go beyond a traditional health plan. Blue365 features ongoing deals, as well weekly specials. You can log into My Health Toolkit®, online or through the mobile app, to see what savings are currently available. Once they’ve logged in, they can find “Member Discounts” under the Resources tab. This is an added-value discount program. Its services and discounts are in addition to, but not included in, the services and benefits covered under your health plan.
If Wegovy is not covered or too expensive, consider using a SingleCare discount card or coupon. Different pharmacies offer different prices for the same medication. Wegovy is one of the most expensive weight loss medications, with an average retail cost of $1,849 per package, which is usually four pens or a one-month supply. Use a Novo Nordisk manufacturer coupon.
If an employer-sponsored healthcare plan does not cover Wegovy, you can ask your healthcare provider to prove why you need it covered. Wegovy has a sample letter that healthcare providers can use as a template. You can then submit the letter to your insurance company to see if they’ll consider covering the cost. Keep in mind that there are other prescription weight loss medications, like Saxenda, that your health insurance plan may cover if it doesn’t cover Wegovy. Some medications, like Mounjaro, are approved for managing blood sugar levels in adults with Type 2 diabetes, but they are sometimes prescribed off-label for weight loss.