Does BCBS cover Wegovy for weight loss?

Blue Cross Blue Shield is one of insurers which may not agree to cover certain medications unless a Health Care provider Summit a prior authorization form showing it’s medically in necessary.

What is Wegovy?

Wegovy is actually a brand name of medication. This brand is approved by food and drug administration (FDA) for weight loss in certain patient’s children of 12 age and older. It is advised to use it together with a reduced calorie diet and increased physical activity. 

It completely depends on your specific insurance plan; Blue Cross Blue Shield (BCBS) may cover Wegovy if patient have specific criteria. For example- include a body mass index (BMI) at a certain level and weight related medical condition. Some other plans may require prior authorization after that they cover Wegovy. Before They got agree to cover the medication, they will request more information from the prescriber.

Wegovy coverage of Blue Cross Blue Shield

Blue Cross Blue Shield is a large Health Care Insurance Company of United States. Insurance company is comprise of 34 independent, locally operated companies across the country. Insurance Company covered nearly 118 million people in December 2023, which is actually one in three Americans.

Every insurance plan of BCBS varies in what they cover just like medications. However, in some medical cases, insurance plans require prior authorization which is also called pre-authorization after that the company approve Medical Services, procedure and medicine. This insurance plan and ensures that treatment is medically necessary for you. Wegovy which is a prescription of weight loss medication often required prior authorisation before the Insurance Company covered. So, it is clear there are chances of your BCBS plan will require prior authorisation after that the company covers Wegovy. This is also truth that the authorization your plan is not a guarantee to cover Wegovy medications.

Wegovy prior authorization criteria

it is important to ensure a prior authorization that a drug is being prescribed safely and is of medical necessity. In most of the cases, your insurance company will initiate the prior authorization for Wegovy and will work with your BCBS plan to complete the request. If you get the approval of the prior authorisation, the medication will be covered by insurance company. It is also thing to remember that it may only be covered for a certain length of time. And when the time period ends, the medication coverage may need reapproval. In most of the cases it is handled by your pharmacy, Insurance Company and health care professional. The time completely depends on your plan. So, you need to check with your doctor pharmacist or BCBS insurance administration about the time period of your Wegovy coverage and when the time period ends.

If patients want to meet the Wegovy pre-authorization criteria then he will have to meet the eligibility requirements the FDA approved it for-

* Adults with a BMI of 30 or higher

* Adults with a BMI of 27 or higher and at least one weight related medical condition just like high blood pressure, high cholesterol type two diabetes.

*  Children 12 years and older with a BMI in the 95 percentile or higher 

Form of prior authorization of Blue Cross Blue Shield

form of prior authorization of the Blue Cross Blue Shield will vary by plan. Typically, you need to give information, date of birth, prescribers information, the diagnosis for Wegovy (the reason for consuming it) and the dosage prescribed by the physician. Prior authorisation form will also need information that help the plan determine if you meet its criteria for approval. 

The thing to remember is, your health care provider will complete the form of prior authorization and should be familiar with the process. Except of the Wegovy BMI eligibility questions, here are some different questions that may be asked in BCBS prior authorization form: –

* Does the member have a history of pancreatitis.

* Will the member use Wegovy in combination with another glucagon like peptide-1 receptor (GLP 1) agonist?

* Will the member participate in a weight loss regimen including low calorie diet increase physical activity and behavioural modifications during the treatment of Wegovy.

* If the member has failed and tried unknown GLP 1 agonist weight loss medication within 6 months.

* For the request of renewal: – achieved loss of at least 5% of the baseline weight.

Also Read : – From Snack to Nutrition: The Complete Story of Khakhra and Its Role in a Balanced Diet

The process of pre-authorization of Wegovy

When a healthcare provider prescribes Wegovy, the prescription will be sent to the patient’s preferred pharmacy. In case Blue Cross Blue Shield plan requires prior authorization, the health care provider of member will be notified by the pharmacy. After that the health care provider will complete the prior authorization request and submit it to the insurance company. After that a team of physicians, pharmacist or other Healthcare providers will review the forms and documents. After that the team decide whether to approve or deny the prior authorization.

There is possibility that it can take up 10 business days for BCBS to make a final decision. But in case they approved, Wegovy will be covered according to the specifications of the plan and the pharmacy will dispatched the drug. But if the company denied, BCBS will notify the prescribing HealthCare provider. The patient has an option to choose to pay the full out-of-pocket cost are use and alternate medication prescribed by their Healthcare provider. On the behalf of their patient, the health care provider can submit an appeal and can explain why they actually need the medication covered by insurance. 

What is the cost of Wegovy?

If you do not have any insurance or any discounts applied, application has a list price of $1349.02 Per package. In a complete year this is equivalent to about $16188 per year. Blue Cross Blue Sheild plan agreed to cover Wegovy, the copy can vary depending on the plan. Thing to remember is that the BCBS plan of different people may be different from another’s.

There may be other options if you want to buy Wegovy lower cost. Option one is you can use a savings offer from the drug manufacturer or a prescription discount card. Another option, single care offers a free Wegovy coupon that can help you to save money. If you want to find the most accurate price, then you need to enter the correct dosage and quantity for your Wegovy prescription on the singlecare coupon page. After that choose the coupon for your preferred pharmacy. Now you need to save the coupon and show it to your pharmacy so they can apply the savings.

How can you check whether your BCBS plan covers Wegovy or not?

You can check it by reading your plan documents. You may also check your plans website or call their toll free phone number on the back of your insurance card.

FAQs