Blue Cross Blue Shield (BCBS) is among the largest healthcare insurance providers in the United States, comprising 34 independent, locally operated companies. Each BCBS insurance plan varies in its coverage details, including medications for weight loss. This article aims to provide a comprehensive overview of how Blue Cross Blue Shield Tennessee handles coverage for weight loss medications, with a focus on Wegovy, a popular prescription drug for weight management.
Prescription Drug Benefits: An Overview
A 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 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, which is the amount you pay when you get a prescription.
Formularies and Drug Lists
Your health plan may use one or more drug lists. Most plans use the Lowest Net Cost Formulary, which lists prescription drugs chosen by an independent panel of doctors and pharmacists for their effectiveness and cost-efficiency in treating specific conditions. Preferred drugs on this formulary typically have lower out-of-pocket costs. However, individuals retain the freedom to choose the medication that works best for them in consultation with their doctor.
Non-Formulary Status and Exclusions
From time to time, the pharmacy committee may decide to no longer cover some drugs, moving them to nonformulary status when other safe, effective, less costly alternatives are available. Additionally, some plans may exclude coverage for certain categories of drugs, such as those for weight loss, fertility, or sexual dysfunction.
Specialty and Maintenance Drugs
Specialty drugs are prescription medications used to treat complex or chronic medical conditions like cancer, rheumatoid arthritis, multiple sclerosis, and hepatitis. Some members are subject to separate management programs for specialty drugs covered under their medical benefit, requiring prior authorization for certain medical (injectable or infusible) specialty drugs. Some infused specialty drugs must be administered at a specific site of care, such as at home or at an infusion suite.
Read also: Weight Loss Guide Andalusia, AL
Maintenance drugs are prescription drugs you take on a long-term basis to treat a chronic condition or for routine use, such as birth control pills. Prescriptions for these products often can be filled for 90 days at a time.
Preventive Drugs
These are drugs that may help prevent serious illnesses and complications. Taking preventive drugs, as directed by your doctor, may help you live a healthier life today and avoid serious illness in the future. The Affordable Care Act (ACA) requires most health plans to cover certain drugs at $0 cost to members. Also, IRS guidelines for high-deductible health plans provide that preventive care, including prescription medications used for preventive purposes, can be excluded from the deductible.
Generic Medications
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, meaning they will pay more for a brand-name drug if they opt to fill it instead of the generic version when a generic equivalent is available.
Medication Adherence Program
The treatment of chronic illnesses often requires the long-term use of prescription drugs. 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.
Understanding Prior Authorization
In some cases, insurance plans require prior authorization-also known as pre-authorization-before they approve medical services, procedures, or medicines. This ensures the treatment is medically necessary for the patient. Prescription weight loss medications, such as Wegovy, often require prior authorization before they’re covered. So, there is a chance your BCBS plan will require prior authorization before it covers Wegovy. Different pharmacies offer different prices for the same medication. A prior authorization ensures a drug is being prescribed safely and is of medical necessity.
Read also: Beef jerky: A high-protein option for shedding pounds?
Wegovy Coverage Under Blue Cross Blue Shield
Blue Cross Blue Shield (BCBS) may cover the cost of the weight loss medication Wegovy, depending on your BMI and weight-related health conditions, but it may require prior authorization. Wegovy is a brand-name medication approved by the Food and Drug Administration (FDA) for weight loss in certain patients, including children 12 years and older. It is also approved to reduce cardiovascular risk in adults with obesity or who are overweight. Depending on your specific insurance plan, Blue Cross Blue Shield (BCBS) may cover Wegovy if you meet specific criteria. Some plans may require prior authorization before they cover Wegovy, meaning they’ll request more information from the prescriber before agreeing to cover the medication.
Prior Authorization Criteria for Wegovy
Criteria for prior authorization approval of Wegovy for adults include a BMI of 30 or higher or a BMI of 27 or higher with at least one weight-related medical condition. Prior authorization approval can expire. In order to meet the Wegovy pre-authorization criteria, patients will have to meet the eligibility requirements the FDA approved it for.
The Prior Authorization Process
In most cases, your healthcare provider will initiate the prior authorization for Wegovy and will work with your BCBS plan to complete the request. Once a healthcare provider prescribes Wegovy, the prescription will be sent to the patient’s preferred pharmacy. If their Blue Cross Blue Shield plan requires prior authorization, the pharmacy will notify the member’s healthcare provider. The healthcare provider will then complete the prior authorization form and submit it to the insurance company. The Blue Cross Blue Shield prior authorization form for Wegovy will vary by plan. Typically, the form may ask for your contact information, date of birth, prescriber’s information, the diagnosis for Wegovy (reason for taking it), and the dosage prescribed by your healthcare provider. The prior authorization form will also ask questions that help the plan determine if you meet its criteria for approval. Remember, your healthcare provider will complete the form and should be familiar with the process.
It can take up to 10 business days for BCBS to make a final decision. If the prior authorization is approved, the medication will be covered according to the specifications of the plan, and the pharmacy will dispense the drug. If denied, BCBS will notify the prescribing healthcare provider. The patient can then choose to pay the full out-of-pocket cost or use an alternate medication prescribed by their healthcare provider.
Cost of Wegovy
Wegovy costs an average of $1,850 for a 28-day supply without insurance or coupons. Costs vary by pharmacy and location, however, so you may pay more or less. If your Blue Cross Blue Shield plan covers Wegovy, the copay can vary depending on the plan. There may be other options to lower the cost of Wegovy, such as using a savings offer from the drug manufacturer or a prescription discount card. SingleCare offers a free Wegovy coupon that can help you save over $600, depending on your location and pharmacy. To find the most accurate price, enter the correct dosage and quantity for your Wegovy prescription on the SingleCare coupon page. Then, choose the coupon for your preferred pharmacy.
Read also: Inspiring Health Transformation
Checking Your Plan Documents
The first step in determining if Wegovy is covered by your plan is to check your plan documents. These should provide information about coverage details and drug formularies, which are the prescription medications your plan covers.
Navigating Your Blue Cross Blue Shield Benefits
To get access to up-to-date Anthem Pharmacy coverage for your drug list, log in and automatically connect to the current drug list that applies to your pharmacy benefits. If your health plan is located in a state where you do not reside, choose the state of your health plan to access the correct drug list. The medications on your drug list are chosen based on a number of factors including how well they work, value to patients and safety.
Additional Considerations
- PreventiveRx Benefit: These lists apply to members whose plans include the PreventiveRx benefit.
- Specialty Pharmacy: This list includes the specialty drugs that must be filled through a participating specialty pharmacy for coverage to be provided.
- Specialty Medications: This list of specialty medications, if covered by a member’s plan, are not covered under the pharmacy benefit.
- Home Delivery and Rx Maintenance 90: These lists are for members who refill prescriptions through home delivery or at a Rx Maintenance 90 pharmacy. If you are eligible for this service, please call the home delivery pharmacy at 855-811-2218.
- ACA $0 Covered Drug List: The Affordable Care Act (ACA) requires most health plans to cover certain drugs at $0 cost to members. View the ACA $0 Covered Drug List.