In a world where obesity is on the rise, achieving a healthier weight has become a top priority for many. While some find success with traditional methods like diet and exercise, others require additional support. This has led to an increased interest in prescription weight loss medications as a potential solution for those struggling to lose excess pounds. Blue Cross Blue Shield (BCBS) of Oklahoma recognizes the severity and health consequences associated with being overweight and offers coverage for certain weight loss medications, such as Wegovy and Saxenda, provided that members meet specific plan eligibility requirements.
While prescription weight-loss medications can help people who are obese to lose weight and reduce their risks for related illnesses such as diabetes, cardiovascular disease, and strokes, their costs can be a great barrier to many people.
Understanding BCBSOK's Approach to Medication Coverage
Blue Cross and Blue Shield of Oklahoma (BCBSOK) is committed to providing its members access to safe, appropriate, and cost-effective healthcare within their plan benefits. The drugs included on your drug list are chosen based on their safety, cost, and effectiveness. While doctors are encouraged to prescribe drugs on the list, treatment decisions are ultimately made between you and your doctor.
Drug List and Pharmacy Benefits
To understand your coverage, you need to know which drug list your plan uses. You can access this information and other materials about covered medications by visiting the BCBSOK website and clicking on the Pharmacy tab.
When prescription drugs are bought from an out-of-network pharmacy, additional charges may apply. You may be responsible for paying the difference between the cost of a brand-name drug and a generic drug if a generic was also available.
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Exclusions
Coverage for certain agents or medication categories may be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility, and Compounds. Any drug not found on the drug list is not covered.
Cost Sharing
Here's a breakdown of the cost-sharing structure for prescription drugs under a sample BCBSOK plan:
- Generic Drugs: 20% Coinsurance after deductible
- Preferred Brand Drugs: 30% Coinsurance after deductible
- Non-Preferred Brand Drugs: 35% Coinsurance after deductible
- Specialty Drugs: 45% Coinsurance after deductible
Certain generic and specialty drugs may have a higher cost-share amount than is listed.
Combined Medical and Drug Deductible and Out-of-Pocket Maximum
Here are the individual and family deductible and out-of-pocket maximum amounts:
- Individual Deductible: \$1,000.00
- Family Deductible: \$2000 Per Person: \$1000
- Individual Out of Pocket Maximum: \$9,200.00
- Family Out of Pocket Maximum: \$18400 Per Person: \$9200
Weight Loss Medication Coverage Criteria
Blue Cross Blue Shield may approve your coverage for Semaglutide and Saxenda if you have a Body Mass Index (BMI) of 30 or more. Increased BMI alone might not cause insurance coverage for services. But if you have a BMI of 27 and suffer from at least one of the health conditions associated with obesity, like cardiovascular disease (CVD), hypertension, type 2 diabetes, obstructive sleep apnea, or impaired glucose tolerance, you may receive cover for care for both the underlying illness and the excess weight.
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Blue Cross Blue Shield requires its members to try to change their lifestyle through exercise and diet if they use one of the five weight-loss medications-Contrave, Saxenda, Qsymia, Wegovy, or Xenical. They should try a lifestyle change for at least six months before getting a prescription for a weight-loss medication. 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.
Prior Authorization (PA) Process
BCBSOK utilizes a prior authorization (PA) process to ensure appropriate medication use. This process requires you or your prescribing healthcare provider to obtain approval from BCBSOK before certain medications are covered.
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 BCBSOK 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.
BCBSOK 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, BCBSOK 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. BCBSOK 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, BCBSOK 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.
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GLP-1 Medications and Automation Technology
To ensure the appropriate use of GLP-1s as indicated for diabetes, BCBSOK is making it easier for some of its members with diabetes to bypass the prior authorization process.
In June 2023, BCBSOK implemented ‘smart’ automation technology at the pharmacy counter to assist with PA review requirements for GLP-1 drugs covered by the pharmacy benefit. The technology reviews documented medical diagnosis of Type 2 diabetes and claims history for other diabetes medications like insulin. When members have a pharmacy claim for a GLP-1 diabetes drug and BCBSOK has documentation of both the Type 2 diabetes diagnosis and claims history for other diabetes medications, members are flagged as having met the PA criteria and a PA request is not needed. All members need is a prescription for their medicine. Medical chart notes are only required in cases where BCBSOK does not have a member’s diabetes diagnosis and other diabetes medication history on file.
Beginning January 1, 2024, members using a GLP-1 diabetes drug who do not have a diabetes diagnosis and other diabetes medication history on file will be required to go through the PA process. If your patient does not have a Type 2 diabetes diagnosis in their medical claims history and prescription history for other diabetes drugs, you may need to submit documentation of the missing information to meet the new PA criteria.
If your patient has an existing PA approval for a GLP-1 diabetes drug, the PA will remain in effect until the expiration date stated on the PA approval notice.
Starting in 2024, Medicare members will also need PA approval for GLP-1 coverage consideration to treat Type 2 diabetes.
BCBSOK and Prime Therapeutics continue to monitor market changes, abnormal pharmacy dispensing, and medication utilization.
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.
An optional pharmacy benefit program for members beginning GLP-1 therapy became available April 1, 2024, for some employer groups with Prime Therapeutics.
How to Verify Your Benefits
While your healthcare provider can verify your benefits, it’s 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 ensured that your plan covers weight loss medication, you’ll want to know the requirements. Each plan has a unique set of standards and conditions that, when met, establish medical necessity to the insurance’s satisfaction.
Navigating the Authorization Process
Once your benefits have been verified, you’ll meet with your 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.
You may begin visiting a dietician if your plan calls for a medically supervised weight loss program. Appointments are typically monthly throughout the life of the plan.
Steps for Authorization
- Gather Medical Records: Your relevant medical records will be collected and sent to the Blue Cross Blue Shield clinical review section.
- Await Determination: A determination may take up to four weeks, but it usually only takes two weeks. You will be informed about the acceptance or denial as soon as they hear from the insurance company. If you’re approved, your weight loss treatment can start.
- Appeal if Necessary: If you’re not approved, examine the decision and follow up with the insurance.
Ensuring Approval
It’s essential to complete the patient health history questionnaire honestly, as this will be translated into your medical record, which Blue Cross Blue Shield 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, get copies of your report to show that you’ve been diligently following up and following any advice your previous practitioner gave.
Maintaining complete compliance with the standards outlined in the medical policy is the most crucial thing you should follow to increase your likelihood of acceptance by any insurance provider.
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 Weight Loss Medications
The Food and Drug Administration (FDA) has approved several medications to help people who are overweight or obese lose weight. These medications must be taken with a doctor’s prescription and should be taken under medical supervision.
They include:
- GLP-1 agonists, including liraglutide (Saxenda) and semaglutide (Wegovy)
- phentermine/Topiramate (Qsymia)
- setmelanotide (Imcivree)
- orlistat (Xenical)
- naltrexone/bupropion (Contrave)
Glucagon-like peptide-1 (GLP-1) drugs are used to treat diseases like type 2 diabetes and obesity. GLP-1 medications have been shown to lower blood pressure, cholesterol, and weight and improve cardiovascular risks. GLP-1s function by imitating hormones that control several bodily functions, including hunger, digestion, and blood sugar.
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.
Important Considerations for Wegovy
- Possible thyroid tumors, including cancer: Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Wegovy® and medicines that work like Wegovy® caused thyroid tumors, including thyroid cancer.
- Pregnancy and Breastfeeding: Wegovy® may harm your unborn baby. It is not recommended for women who are pregnant or plan to become pregnant, or are breastfeeding or plan to breastfeed.
- Drug Interactions: Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Wegovy® may affect the way some medicines work and some medicines may affect the way Wegovy® works. Tell your healthcare provider if you are taking other medicines to treat diabetes, including sulfonylureas or insulin.
- Pancreatitis: Stop using Wegovy® and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting.
- Gallbladder problems: Wegovy® may cause gallbladder problems, including gallstones. Some gallstones may need surgery.
- Hypoglycemia: Increased risk of low blood sugar (hypoglycemia), especially those who also take medicines for diabetes such as insulin or sulfonylureas. Talk to your healthcare provider about how to recognize and treat low blood sugar and check your blood sugar before you start and while you take Wegovy®.
- Kidney problems (kidney failure): In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse.
- Severe stomach problems: Stomach problems, sometimes severe, have been reported in people who use Wegovy®.
- Serious allergic reactions.
- Change in vision in people with type 2 diabetes.
- Increased heart rate: Wegovy® can increase your heart rate while you are at rest.
- Depression or thoughts of suicide: You should pay attention to any mental changes, especially sudden changes in your mood, behaviors, thoughts, or feelings.
- Food or liquid getting into the lungs during surgery: Wegovy® may increase the chance of food getting into your lungs during surgery or other procedures that use anesthesia or deep sleepiness (deep sedation).
What If Insurance Won’t Cover My Weight Loss Medication?
If Blue Cross Blue Shield does not cover your medication, you may get other options for more affordable medication coverage. Unfortunately, medications like WeGovy and Ozempic will typically still cost $700 or more.
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.
Prime Therapeutics LLC
Prime Therapeutics LLC is a separate company contracted by Blue Cross and Blue Shield of Oklahoma to provide pharmacy solutions. BCBSOK contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSOK, 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.
Availity
Availity is a trademark of Availity, LLC., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSOK.