Major insurer drops GLP-1 coverage: What this means

Blue Cross Blue Shield of Michigan and Blue Care Network sent a letter to physicians and policyholders dated June 6, 2024. Starting August 1, 2024, the insurer will make it much more difficult for policyholders to be approved for GLP-1 drugs, such as Zepbound (tirzepatide), Wegovy (semaglutide), and Saxenda (liraglutide). And, no one will be covered for these drugs as of January 1, 2025.

Many people will suddenly have a decision to make: pay for their medication out of pocket, stop taking it, or move to a compound pharmacy version (that lacks FDA approval).

Is BCBS dropping GLP-1 coverage in all states?

No. The newly announced changes we’ll discuss below are applicable ONLY to people insured by one of Blue Cross Blue Shield of Michigan’s “fully insured large group commercial” policies. They won’t impact you if your employer offers a “self-insured” plan through BCBSM.

However, sweeping changes like this may happen across other insurers, so staying informed is important.

All current Zepbound, Wegovy, and Saxenda prior authorizations expire July 31, 2024

Here’s exactly what’s changing and when. This text is directly from the letter BCBSM sent to policyholders.

As of August 1, 2024: “Prior authorizations for these drugs will end at midnight on July 31. A new prior authorization request will be required, and new prior authorization criteria will be applied for these members for dates of service from Aug. 1 through Dec. 31, 2024.

Some members will require a new prescription to align with the new prior authorization criteria if the original prescriber didn’t have an established relationship with the member or hasn’t seen the member in person.

For members with a plan renewal date other than Jan. 1, the new prior authorization will end prior to the renewal date.”

You can apply for a new PA

If you have a Zepbound, Wegovy, or Saxenda prior authorization that now expires July 31, your doctor can file a new PA. However, there are some big hurdles you have to jump to get approved.

“The following new criteria will apply for fully insured large-group commercial members:

The member must be 18 years or older and have a body mass index of 35 or higher.
The medication must be prescribed by a healthcare provider who has an established relationship with the member and has seen the member in person.
The prescriber must document the member’s current baseline weight (within 30 days).
The prescriber must document the member’s active participation in a lifestyle modification program (working with a coach, tracking food and exercising) for a minimum duration of six months before the prior authorization request. The prescriber will no longer be able to attest to a member’s participation. The prescriber must submit documentation, or the request will be denied.
The member must enroll and participate in the Teladoc® Health program for weight management. This is a program at no cost to eligible members that offers easy-to-use tools and support. The prescriber must submit documentation of the member’s active participation, or the request will be denied.”

“In addition to the requirements above, Saxenda, Wegovy, and Zepbound:

Can’t be used in combination with other weight loss products or other products that contain GLP-1 agonists
Aren’t covered for members with Type 2 diabetes”

Problem 1: BMI criteria is too high

In BCBSM’s new GLP-1 criteria, the patient must have a BMI of 35 or higher. That seems too high.

Let’s look at an example

Woman
5′ 2″
186 pounds
Age 54

This woman’s BMI would be 34… one point too low to be considered for GLP-1 coverage at BCBSM.

However, if you look at all the calculations for healthy weight goals, she should be 123.1 pounds. That means she’s 62.9 pounds overweight. Yet, she won’t qualify for weight loss management treatment if she has a fully insured commercial insurance plan from BCBSM.

Problem 2: No telehealth options

One of the most interesting things about the new criteria BCBSM laid out for its new GLP-1 prior authorizations — which will only be valid from August 1–December 31, 2024 — is that you have to see your doctor in person. That eliminates telehealth options, such as Weight Watchers Clinic, Form Health, and Noom Med.

This bothers me. As of 2023, only 8,263 doctors were certified as obesity specialists by the American Board of Obesity Medicine (ABOM). According to the Federation of State Medical Boards, that’s out of 1,044,734 licensed doctors in the United States. Hmmm. Something is not adding up there. This is why it’s so difficult for many of us to find a doctor who understands weight management issues and can treat us locally.

I live in a semi-rural area, and my primary care physician readily admits she’s not an obesity specialist. She also communicated that her practice doesn’t have the knowledge or bandwidth to handle complicated prior authorization paperwork requests. They also don’t have time to write and call in monthly GLP-1 prescriptions that require patients to titrate up to different doses throughout the care plan.

That’s why I sought out a telehealth option. I see an endocrinologist, but all contact is online. My labs are done locally and then uploaded to a portal. BCBSM members who found this same solution will not have their new PAs approved come August 1. That stinks.

Problem 3: You need 6 months of a lifestyle modification program under your belt

The next problem is the new requirement that the patient undergo at least six months of a lifestyle modification program before the new PA. Well, someone working with Weight Watchers or Noom or a similar program may qualify on that point, but the PA would ultimately be denied since the patient doesn’t see the doctor in person.

If you track your food and exercise in an app, that might count, but from the language in the BCBSM letter, you’d also need to work with a coach. It’s unclear if the food and exercise tracking has to be done in concert with the coach or if those components could be broken out separately. I bet a ton of people will be denied due to a lack of “proof” that they’ve been modifying their lifestyle, including a calorie-restricted diet and the addition of exercise.

Problem 4: The PA process is a nightmare for your doctor

Reading through the new PA criteria, BCBSM will ask your doctor for a lot of documentation. Will your doctor’s office be prepared to provide this type of support? I worry many doctors will have to make the difficult decision not to prescribe GLP-1 medications because they don’t have the bandwidth or expertise to handle all the new, required paperwork.

It’s a no-win situation for BCBSM patients who need medications such as Zepbound, Wegovy, and Saxenda.

No GLP-1 coverage as of January 1, 2025

Finally, even if a policyholder jumps through all the hoops and successfully gets a PA approved in August, it will also expire on December 31, 2024. There will be no coverage for GLP-1 drugs after that.

Here’s what the letter says:

As of January 1, 2025: “Coverage for GLP-1 weight loss drugs for fully-insured large group commercial members will end starting Jan. 1, 2025. For group members with a plan renewal date other than Jan. 1, the coverage will end on the renewal date.”

Check to see if you qualify to get Zepbound, Wegovy, or Saxenda at a discount

If you lose your coverage for Zepbound, Wegovy, or Saxenda, you may be eligible to save some money off the retail cost of the medication by using the manufacturer’s savings coupon.

Visit these pharmaceutical company websites for more information on their savings programs:

The wrap-up

This is tough news for anyone covered by a fully insured large group commercial policy from Blue Cross Blue Shield of Michigan. While I agree that there should be controls on who gets this medication and that the cost must be fairly shared between the insurer and patient, BCBSM’s approach will effectively block GLP-1 coverage from a large number of policyholders.

Are you affected by this change or a similar one by your health insurance provider? Please let me know via email or post about it on the Shots to Shed Pounds Facebook page.