In an era where obesity rates are climbing, achieving and maintaining a healthy weight has become a paramount concern for many individuals. While lifestyle modifications such as diet and exercise remain fundamental, some individuals find these methods insufficient to achieve their desired results. Consequently, prescription weight loss medications have emerged as a potential solution for those grappling with excess weight.
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.
Blue Cross Blue Shield (BCBS) Federal recognizes the critical health implications associated with being overweight and offers coverage for weight loss medications like WeGovy and Saxenda, contingent upon meeting specific plan eligibility requirements. This article aims to provide a comprehensive overview of BCBS Federal's coverage policies for weight loss medications, explore affordable alternatives, and offer guidance on maximizing your chances of approval.
Understanding Blue Cross Blue Shield Federal Coverage Criteria
Before delving into the specifics of weight loss medication coverage, it's crucial to understand the criteria BCBS Federal employs to evaluate and approve coverage requests.
BMI Thresholds
BCBS Federal may approve coverage for semaglutide (Wegovy) and Saxenda if you have a Body Mass Index (BMI) of 30 or higher. A BMI of 27 or higher may also qualify you for coverage if you have at least one obesity-related health condition, such as:
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- Cardiovascular disease (CVD)
- Hypertension
- Type 2 diabetes
- Obstructive sleep apnea
- Impaired glucose tolerance
Lifestyle Modification Requirements
BCBS Federal mandates that members attempt lifestyle modifications, including diet and exercise, for at least six months before considering prescription weight loss medications like Contrave, Saxenda, Qsymia, Wegovy, or Xenical.
The insurance company emphasizes the importance of engaging in structured weight loss programs like Weight Watchers or Noom, or receiving guidance from a healthcare professional regarding diet and exercise.
Verifying Your Benefits
While many clinics offer benefit verification as a complimentary service, it's advisable to contact BCBS Federal directly to inquire about your plan's specific coverage details and criteria. You can also consult your employer-provided or insurance-provided coverage documentation.
Once you've confirmed that your plan covers weight loss medications, it's essential to understand the unique requirements and conditions that must be met to establish medical necessity, as determined by the insurance company.
The Blue Cross Blue Shield Authorization Process
Once all insurance requirements are met, the authorization process starts. Your relevant medical records will be collected and sent to the Blue Cross Blue Shield clinical review section.
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The authorization process typically takes up to four weeks, but often requires only two weeks. You will be notified of the approval or denial decision as soon as the insurance company communicates its determination. If approved, your weight loss treatment can commence.
In the event of a denial, the decision will be reviewed, and a follow-up will be initiated with the insurance company to explore potential avenues for reconsideration.
Maximizing Your Chances of Approval
To enhance your likelihood of securing approval for weight loss medication coverage, consider the following strategies:
- Complete the Patient Health History Questionnaire Honestly: Provide accurate and comprehensive information on the patient health history questionnaire, as this information will be incorporated into your medical record and scrutinized by BCBS Federal.
- Provide Documentation of Prior Weight Loss Attempts: Gather and present any documentation, including medical chart notes, diaries, personal records, or receipts, that substantiate your previous efforts to lose weight through exercise, diet, or medical supervision.
- Obtain Records of Previous Weight-Loss Treatment: If you've undergone prior weight loss treatment, acquire copies of your reports to demonstrate your adherence to the prescribed regimen and any recommendations provided by your previous practitioner.
- Maintain Strict Compliance with Medical Policy Standards: Adhering meticulously to the standards outlined in the medical policy is paramount for maximizing your chances of approval by any insurance provider.
- Adhere to Medically Supervised Diets: Ensure that medically supervised diets are spaced appropriately, typically around 30 days apart, and maintained consistently for several months. Failure to adhere to consecutive monthly visits may result in denial, treatment delays, or the need to restart the program from the beginning.
Overview of Weight Loss Medications
The Food and Drug Administration (FDA) has approved several medications to aid individuals who are overweight or obese in their weight loss efforts. These medications necessitate a doctor's prescription and should be administered under medical supervision.
Commonly prescribed weight loss medications include:
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- 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 employed in the treatment of conditions like type 2 diabetes and obesity. These medications have demonstrated efficacy in lowering blood pressure, cholesterol, and weight, as well as mitigating cardiovascular risks. GLP-1s function by mimicking hormones that regulate various 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 can be an efficient means of reducing your weight when combined with other lifestyle modifications and taken under the guidance of a healthcare practitioner.
These medications are typically prescribed for adults with obesity or overweight with at least one weight-related comorbidity, such as high blood pressure, type 2 diabetes, or high cholesterol.
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.
It's important to note that not everyone is eligible for weight loss drugs, including pregnant women, individuals with certain medical conditions, or those taking specific medications.
A healthcare provider can assess your individual goals, medical history, and current health status to determine whether you are a suitable candidate for prescription weight loss medication.
Addressing Insurance Coverage Denials
If BCBS Federal denies coverage for your weight loss medication, explore alternative options for more affordable coverage. Unfortunately, medications like WeGovy and Ozempic will still typically 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.
Affordable Wegovy Alternatives to Consider
If your BCBS plan does not cover Wegovy or has increased the out-of-pocket cost, there are alternative options to consider. Here are some medications you may want to discuss with your healthcare provider.
Ozempic or Mounjaro
If you’ve been diagnosed with obesity and Type 2 diabetes mellitus at the same time, you may be eligible for a branded GLP-1 RA or GLP-1/GIP RA like Ozempic or Mounjaro.
Ozempic (semaglutide) is an injectable drug prescribed once a week. It has the same active ingredient as Wegovy, semaglutide. The primary difference between Wegovy and Ozempic is their FDA-approved conditions and dosages.
The FDA approved Ozempic to help people with type 2 diabetes manage their blood sugar levels. Similar to Wegovy, it also reduces weight and lowers the risk of serious cardiovascular events in people with type 2 diabetes and known heart disease, such as death, heart attack, or stroke.
Ozempic is given at lower dosages than Wegovy. (The highest dose of Ozempic is 2 mg weekly vs. 2.4 mg weekly for Wegovy.).
Mounjaro is also injected once a week under the skin, and it contains the same active ingredient as Zepbound, tirzepatide. Unlike Wegovy and Ozempic, which have different dosages, Mounjaro and Zepbound are prescribed in the same dosage.
Zepbound is the same as Wegovy, but it stands out because it’s a dual GIP (glucose-dependent insulinotropic polypeptide) and GLP-1 agonist. It reduces appetite and increases fullness, thus supporting weight loss efforts. Studies have shown that Zepbond may achieve greater weight loss than Wegovy.
However, like Wegovy, Zepbound has also seen an increase in out-of-pocket costs under BCBS Federal insurance. Certain insurance plans do not also cover Zepbound completely.
While there hasn’t been a direct comparison between Wegovy and Mounjaro, research of people with type 2 diabetes receiving the highest doses of tirzepatide experienced more weight loss than those taking the 2 mg dose of semaglutide.
Mounjaro and Ozempic are less likely to be covered by insurance when prescribed off-label for weight loss, but if you have type 2 diabetes and need help managing your weight, they may be covered by your insurance, including BCBS.
Compounded Semaglutide
Compounded semaglutide may be an affordable alternative to the brand name Wegovy. Compounded semaglutide has the same active ingredient as Wegovy. Drug compounding is when a doctor, licensed pharmacist or an outsourcing facility blends, combines, mixes, or alters ingredients to meet specific patient needs.
Compounded semaglutide may be prescribed for weight loss by compounding pharmacies, online pharmacies, some health clinics, and providers, especially during medication shortages or when a patient has problems with insurance coverage.
The FDA has a list of drugs that are in shortage, and injectable semaglutide is now in short supply. The FDA understands that patients may resort to compounded formulations of the necessary drugs during prescription shortages.
The FDA advises people who cannot use the FDA-approved version due to an allergy or other special need to use compounded medications. For instance, a person who has trouble swallowing pills can seek a liquid form of a drug from a compounding pharmacy.
The FDA listed Wegovy and Ozempic as having a drug shortage since May 2023, which means they can be compounded.
If you and your doctor determine that compounded semaglutide would be a suitable Wegovy alternative for you, you should be sure that an accredited US-based compounding pharmacy makes it and that a prescription from a licensed healthcare professional is required.
Cost of Compounded Semaglutide
Compounded semaglutide offers a cost-effective solution compared to the brand-name Wegovy.
Maximizing Weight Loss on Compounded Semaglutide
All weight loss medications work best when you adopt a balanced diet and exercise habits. Most medications are prescribed in combination with a reduced-calorie diet and increased exercise.
Have control over food and focus on nutrient-dense foods like lean proteins, whole grains, vegetables, and healthy fats. Limit processed foods, sugary snacks, and high-calorie beverages that could hinder your progress, and eat smaller, more frequent meals to stabilize your blood sugar levels.
As for exercise, aim for at least 150 minutes of moderate-intensity exercise per week, such as brisk walking, cycling, or swimming. It’s also helpful to look for other ways to be active, like using stairs instead of escalators and taking short walks when running errands instead of using your car.
Sticking to the dosage and schedule recommended by your healthcare provider is also important. Compounded semaglutide works best when taken consistently, so ensure you don’t miss doses.
Compounded Semaglutide vs. Brand-Name Wegovy
The table below shows a comparison between compounded semaglutide and brand-name Wegovy.
| Feature | Brand-name Wegovy | Compounded semaglutide |
|---|---|---|
| Cost | Starts at around $1,300/month | Ranges from $199-$299/month at NP2GO |
| Availability | Shortages are common | Readily available from compounding pharmacies |
| Prescription requirement | Requires a prescription from a licensed provider | Requires a prescription from a licensed provider |
| Active ingredient | Semaglutide | Semaglutide |
| FDA approval | FDA-approved for chronic weight management | Not FDA-approved |
| Insurance coverage | Some insurance plans may provide partial coverage | Not covered by insurance |
| Delivery method | Subcutaneous injection (once weekly) | Subcutaneous injection (once weekly) |
| Side effects | Nausea, vomiting, diarrhea, and other potential side effects | Similar to Wegovy (e.g., nausea, diarrhea, constipation) |
| Regulation | FDA-regulated | Overseen by state pharmacy boards |
Additional Resources Offered by Blue Cross Blue Shield
Blue Cross Blue Shield provides access to various resources and programs designed to support members in their weight management journeys, including:
- Blue Distinction Centers: Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for bariatric surgery. Blue Distinction Centers for cancer care provide a full range of cancer services. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for cancer care. Blue Distinction Centers and Blue Distinction Centers+ for cardiac care provide a full range of inpatient cardiac care services; including coronary artery bypass graft surgery (CABG), heart valve surgery, and percutaneous coronary intervention (PCI). Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for cardiac care. Blue Distinction Centers for cellular immunotherapy focus on treatments used to help the immune system fight diseases, such as cancer. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for cellular immunotherapy. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for fertility care. Blue Distinction Centers for gene therapy focus on gene therapies for inherited disorders. The program focuses on FDA-approved gene therapy specifically for ocular disorders used to treat patients with a specific type of inherited blindness. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for gene therapy. Blue Distinction Centers and Blue Distinction Centers+ for knee and hip replacement have demonstrated expertise in total knee and total hip replacement surgeries. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for knee and hip replacement. Blue Distinction Centers and Blue Distinction Centers+ for maternity care demonstrate expertise and a commitment to quality care for vaginal and cesarean section deliveries. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for maternity care. Blue Distinction Centers and Blue Distinction Centers+ for spine surgery provide comprehensive spine surgery services; including laminectomy/discectomy, fusion and decompression procedures for cervical and lumbar spine. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for spine surgery. Access the provider directory of Blue Distinction Centers or Blue Distinction Centers+ designated providers for substance use treatment. Blue Distinction Centers and Blue Distinction Centers+ for transplants provide a range of services for heart, lung, liver, kidney and bone marrow/stem cell transplants. Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. A Local Blue Plan may require additional criteria for providers located in its own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers’ need for affordable health care. Each provider’s cost of care is evaluated using data from its Local Blue Plan. Providers in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of care evaluation(s) must meet BDC+ national criteria. National criteria for BDC and BDC+ are displayed on www.bcbs.com. Individual outcomes may vary. For details on a provider’s in-network status or your own policy’s coverage, contact your Local Blue Plan and ask your provider before making an appointment.
- Weight Management Program by Livongo: Eligible members can access a digital scale and ongoing support to manage their weight and improve their health.
- Blue365: Discover deals on various health and wellness brands to support your fitness goals.
- Telehealth Nutrition Counseling: Connect with registered dieticians for personalized meal plans and nutritional guidance via phone or computer.