Does Blue Cross Blue Shield cover Wegovy?

Wegovy (semaglutide) is a weekly injectable weight-loss medication. The active ingredient semaglutide was approved by the U.S. Food and Drug Administration (FDA) in 2021 for chronic weight management in adults and children 12 and older with obesity (BMI of 30 or more) and for adults who are overweight (BMI of 27 or more) with one or more weight-related health conditions, such as type 2 diabetes or high blood pressure. In addition to weight loss, Wegovy is FDA-approved to reduce the risk of major adverse cardiovascular events like heart attack and stroke in obese or overweight adults with heart disease.

With an estimated list price of $1,349 per month, the cost of Wegovy is very high, especially for those without adequate insurance coverage.

Your Blue Cross Blue Shield plan will likely cover Wegovy if you meet the eligibility criteria, but coverage depends on the details of your insurance plan.

Blue Cross Blue Shield (BCBS) is one of the largest health insurance companies in the United States. They offer many plans that cover medical care, including doctor visits, hospital stays, and prescription medications to help you manage your health.

Keep reading to find out if BCBS will cover Wegovy, the drug coverage prior authorization criteria, and alternative options if you can’t get coverage.

Is Wegovy covered by Blue Cross Blue Shield (BCBS) for weight loss?

Many Blue Cross Blue Shield (BCBS) plans will cover weight loss medications like Wegovy, but it depends on the specific details of your insurance plan. BCBS provides coverage for various medications, including weight loss drugs like Wegovy, although several factors can affect whether it’s covered. To verify coverage, call your insurance provider or employer if you have employer-sponsored insurance. You can usually find their number on the back of your insurance card. Novo Nordisk, the manufacturer of Wegovy, also provides a tool that allows you to check your insurance coverage.

BCBS is not just one company, but a group of 34 independent insurance companies. These companies are part of the Blue Cross Blue Shield Association, and some of the well-known ones include Empire and Anthem.

Each insurance company in the Blue Cross Blue Shield group sets its own rules and coverage options, which can vary depending on the state and the specific plan you have.

Key factors that influence coverage

1. Plan type: Whether you have an HMO, PPO (provided by Blue Shield of California), employer-sponsored insurance, or another type of plan can impact whether Wegovy is covered.
2. Prior authorization: BCBS may require proof that Wegovy is medically necessary, such as evidence of health conditions related to weight. Even if Wegovy is covered, prior authorization is usually required.
3. Employer-specific policies: Weight loss medications can be expensive and are covered by some insurance plans. Most people get insurance through their employers, so it depends on whether the employer has chosen to include weight loss coverage.

Does BCBS cover Wegovy for heart disease?

BCBS may cover Wegovy for people with heart disease, but it depends on your situation. For example, BCBS may provide coverage if you have a BMI of 27 or higher and a weight-related health condition like heart disease. Each plan is different, so coverage for Wegovy will vary based on your plan type, medical history, and if the treatment is medically necessary.

Also, BCBS requires prior authorization for expensive medications like Wegovy. That means your doctor will need to submit documentation to BCBS to show that the medication is necessary for your health condition.

Blue Cross Blue Shield coverage criteria for Wegovy

If a BCBS plan covers Wegovy, patients will be required to meet specific criteria. People aged 12 and older may qualify for Wegovy if they:

• Patient is 12 years of age or older, and;
• Patient has a BMI (body mass index) of 30 or higher, or;
• Patient has a BMI (body mass index) of 27 or higher and at least one weight-related health condition like diabetes, high blood pressure, heart disease, or sleep apnea.

Additionally, you must also complete a full medical evaluation, including lab tests and a review of your current medical history.

How much does Wegovy cost?

According to NovoCare, the list price (what the manufacturer charges pharmacies) of a 28-day supply of Wegovy auto-injector pens is $1,349.02, which comes to $337.3 per week and $16,188.20 per year.

There’s currently no generic version of Wegovy available in the United States. However, even without insurance, there are still ways for you to pay less than the average retail price. Keep reading below to learn more.

How to check if your BCBS plan covers Wegovy

BCBS is a network of independent insurance companies and licensees, including Blue Cross, Blue Shield, Blue Cross and Blue Shield, Highmark, Anthem, CareFirst, and others. Each of these companies has its coverage options and policies which are subject to change at any time.

To check if your BCBS plan covers Wegovy, you can:

• Check your plan’s formulary: This is the list of drugs covered by your plan found on your BCBS company’s website or by logging into your account. The formulary is updated frequently and can change from month to month so always check the date to make sure you are reviewing the most recent version of the formulary.
• Call the phone number on your insurance card: A representative from your insurance company can provide specific information about your coverage.
• Use the free coverage check tool on the Wegovy website: You can call 1‑844‑Novo4Me or complete the online form and an agent from Novo Nordisk will get back to you with your coverage information.

Once you’ve determined that your BCBS plan covers Wegovy, consider asking your insurance provider these questions:

• Is prior authorization required?
• Have I met my annual deductible and out-of-pocket requirements?
• How much will my copay for Wegovy be for the year?
• Is there an out-of-pocket limit or maximum on my insurance plan? Once reached, how much will my copay be for Wegovy coverage?
• Are there any quantity limits? For example, can I get a 90-day supply to save money?
• If my coverage request is denied, what do I need to do to submit an appeal?

If your employer-sponsored plan doesn’t cover Wegovy, ask your healthcare provider to provide a letter explaining why you need it. You can then submit this letter to your insurance company to request coverage. If your insurance provider still declines coverage for Wegovy, you can also consider enrolling in a clinical trial to receive low-cost or free Wegovy if qualified.

Drug tier

Wegovy is often placed in a higher drug tier by BCBS plans. Most insurance plans, including BCBS, provide a drug list of its covered drugs in several tiers. Drug tiers determine how much you’ll pay out-of-pocket. Lower tiers have the lowest copays and coinsurance costs, and the higher tiers have the highest copays and coinsurance costs.

BCBS drug tiers may include:

• Tier 1: typically includes preferred generic drugs
• Tier 2: typically includes non-preferred generic drugs
• Tier 3: typically includes preferred brand name drugs
• Tier 4: typically includes non-preferred brand name drugs
• Tier 5: typically includes specialty drugs
• Tier 6: typically includes non-preferred specialty drugs

Prior authorization

Many BCBS plans require prior authorization for Wegovy. This means your healthcare provider must submit a request to your insurance company explaining why you need this specific medication. While the prior authorization process varies by plan, the process typically involves:

1. Your doctor submitting clinical information.
2. The insurance company reviewing the request.
3. Approval or denial of coverage.

You can check if your specific insurance plan requires that your healthcare provider submit a prior authorization for Wegovy by reviewing your plan’s drug formulary. If “PA” is written next to Wegovy, that means prior authorization is required for coverage.

If your insurance provider declines the prior authorization, you can submit an appeal with the help of your healthcare provider who can provide more information and a letter of medical necessity.

Coverage limits

Wegovy coverage under BCBS may vary based on your plan but here are some general limits:

• Prior authorization: Most BCBS plans require prior authorization for Wegovy. Your healthcare provider must submit a request to BCBS with supporting medical info to show that Wegovy is medically necessary for your condition.
• Medical necessity: BCBS will likely require proof that Wegovy is medically necessary. This means having a BMI of 30 or higher or a BMI of 27 or higher with weight-related health conditions.
• Duration of coverage: Coverage may be for a certain time based on your progress and ongoing need for the medication. BCBS may review your treatment after a certain period to see if continued coverage is needed.
• Formulary restrictions: Some BCBS plans may put Wegovy on a higher drug tier which means higher copays or out-of-pocket costs.
• Plan-specific limits: Since BCBS is a federation of independent companies, coverage limits can vary between states and plans. Some plans may have limits on how much Wegovy is covered per year or who qualifies for coverage.

Alternatives if Wegovy is not covered by insurance

If your insurance plan doesn’t approve coverage, there are cheaper alternatives to Wegovy for weight loss. Speak with your healthcare provider about these alternatives to find out if any of these medications are right for you.

• Compounded semaglutide:  Custom-made medication made at a compounding pharmacy and is a cheaper prescription medication than the brand name, but it’s not evaluated by the FDA. It contains the same active ingredient as Wegovy and Ozempic. No insurance is needed. The medication is prescribed online by a licensed healthcare provider.
• Phendimetrazine tartrate: Reduces appetite and supports short-term weight loss when used with exercise, a low-calorie diet, and behavior changes.
• Phentermine-topiramate (Qsymia): Phentermine reduces hunger, topiramate helps you feel full longer and supports weight loss.
• Orlistat: A weight loss medication that blocks some of the fat you eat from being absorbed by your body. Orlistat is sold over the counter as Alli and prescription strength as Xenical.
• Tirzepatide: Tirzepatide (Zepbound and Mounjaro) is a medication for chronic weight management and type 2 diabetes.
• Liraglutide (Saxenda): Helps in weight loss when used with diet and exercise.
• Victoza: Approved for blood sugar control in type 2 diabetes and is used off-label for weight loss.
• Bupropion-naltrexone (Contrave): It’s a combination of two drugs: bupropion which reduces appetite and naltrexone which controls cravings.

How to save on Wegovy

Wegovy is a popular weight loss medication, but there is no generic version available yet. Fortunately, there are several ways to make it more affordable.

• Wegovy Savings Card: Novo Nordisk offers a Wegovy Savings Card program that can help you get discounted or even free Wegovy doses. To see if you qualify, visit the Wegovy Savings Card eligibility page. Commercially insured patients with coverage for Wegovy can pay as low as $0 for a 28-day supply. If your insurance doesn’t cover Wegovy, your out-of-pocket costs are over $849, or you are uninsured, you can pay $650 for a 28-day supply. People with government-sponsored insurance like Medicare and Medicaid are not eligible.
• Prescription discount cards: Programs like GoodRx, SingleCare, and Blink Health offer discounts and coupons that can help you save 3% to 80% off the retail price at participating pharmacies. No insurance is required. You can get these discounts instantly online, for free, without having to sign up or qualify.
• Insurance Coverage: Aetna, Cigna, United Healthcare, BlueCross BlueShield, Molina, and Oscar Insurance are some of the major insurance companies that cover Wegovy. However, most of them require prior authorization (PA). To find out if you have coverage, visit the NovoCare website.
• Free samples from healthcare providers: Some healthcare providers may have free samples of Wegovy that they can provide to patients. These samples can help patients try Wegovy for a short period, but they are not a long-term solution.
• 90-day supply: If your insurance plan covers Wegovy, you can get a 90-day supply. This way, you pay your copay only once for three months instead of every month. Some insurance companies offer this option, but others may not.
• HSA/FSA: If you have a flexible spending account (FSA) or health savings account (HSA), you can use pre-tax dollars to pay for medical expenses, including Wegovy. You can also increase your contributions during the annual open enrollment period.
• Government programs: Medicare, Medicaid, and Tricare may cover Wegovy, but the extent of coverage varies. Veterans receiving care through Veterans Affairs (VA) Health Care may also be prescribed Wegovy as part of the MOVE! Weight Management Program.

Bottom line

Navigating BCBS coverage for Wegovy can be tricky, but understanding your plan’s specific policies and coverage options is essential.

Prior authorization is often required, and the drug is typically placed in a higher tier, which can affect your out-of-pocket costs.

Always check the most recent version of your plan’s formulary or contact your insurance plan directly to determine coverage options. You can also check your insurance coverage on the Novo Nordisk website.

Regardless of the circumstances, there are several options for you to save money which vary based on whether or not you have adequate insurance coverage for Wegovy.