In a world where obesity is rising, having a healthier weight has become a top priority for many people. While some successfully use traditional weight loss techniques like diet and exercise, only some get the desired results. This has led to a growing interest in prescription weight loss medications as a potential option for those struggling to shed excess pounds.
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.
WeGovy (semaglutide) and Saxenda, the two FDA-approved weight-loss drugs that are most successful, can cost up to $1500 per month, and Mounjaro (tirzepatide), the most efficient off-label drug, can cost up to $1,000 per month.
Blue Cross Blue Shield recognizes the severity and health consequences of being overweight and covers weight loss medications like WeGovy and Saxenda — provided you meet plan-eligibility requirements.
Discover how Blue Cross Blue Shield Federal makes weight loss drugs accessible.
Blue Cross Blue Shield Federal Coverage Criteria for WeGovy and Saxenda
Before considering coverage for weight loss medication, it’s important to know the standards the company uses to approve its clients.
Blue Cross Blue Shield may approve your coverage for Semaglutide and Saxenda if you have a Body Mass Index (BMI) of 30 or more.
Increased BMI alone might not cause insurance coverage for services. But if you have a BMI of 27 and suffer from at least one of the health conditions associated with obesity, like cardiovascular disease (CVD), hypertension, type 2 diabetes, obstructive sleep apnea, or impaired glucose tolerance, you may receive cover for care for both the underlying illness and the excess weight.
Blue Cross Blue Shield requires its members to try to change their lifestyle through exercise and diet if they use one of the five weight-loss medications—Contrave, Saxenda, Qsymia, Wegovy, or Xenical. They should try a lifestyle change for at least six months before getting a prescription for a weight-loss medication.
The insurance wants its members to be engaged in diet, exercise, or even a weight-loss program like Weight Watchers or Noom under a healthcare professional’s guidance.
How to verify your own benefits
While we will verify your benefits as a free service, it’s a good idea to call Blue Cross Blue Shield directly to inquire about your plan’s coverage and criteria. You can also read the coverage documentation your employer or insurance gave you.
Once you’ve ensured that your plan covers weight loss medication, you’ll want to know the requirements. Each plan has a unique set of standards and conditions that when met, establish medical necessity to the insurance’s satisfaction.
Once your benefits have been verified, you’ll meet with our healthcare practitioner for consultation. They will document your height, weight, BMI, comorbid conditions, and tried and unsuccessful attempts to lose weight through lifestyle changes alone.
You will begin visiting a dietician if your plan calls for a medically supervised weight loss program. Appointments are typically monthly throughout the life of the plan.
Blue Cross Blue Shield authorization process
Once all the 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.
A determination may take up to four weeks, but it usually only takes two weeks. We will inform you about the acceptance or denial as soon as we hear from the insurance company. If you’re approved, your weight loss treatment can start.
If you’re not approved, we’ll examine the decision and follow up with the insurance.
What Can I Do to Ensure Approval For Weight Loss Medication Coverage?
We will give you a patient health history questionnaire before your consultation. It’s essential to complete it honestly, as this will be translated into your medical record, which Blue Cross Blue Shield will review.
If you have any documentation, including medical chart notes, diaries, personal records, or receipts, of your prior attempts at weight loss, whether by exercise, diet, or medical supervision, bring a copy to be examined and scanned into your chart.
If you’ve undergone previous weight-loss treatment, get copies of your report to show that you’ve been diligently following up and following any advice your previous practitioner gave.
Maintaining complete compliance with the standards outlined in the medical policy is the most crucial thing you should follow to increase your likelihood of acceptance by any insurance provider.
Diets under medical supervision should be spaced for about 30 days and frequently need to occur for several months. Failure to follow visits in consecutive calendar months will frequently lead to denial, delay your treatment, or require you to restart the recommended program from scratch.
An Overview of Weight Loss Medications
The Food and Drug Administration (FDA) has approved several medications to help people who are overweight or obese lose weight. These medications must be taken with a doctor’s prescription and should be taken under medical supervision.
They include:
● 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 used to treat diseases like type 2 diabetes and obesity. GLP-1 medications have been shown to lower blood pressure, cholesterol, and weight and improve cardiovascular risks. GLP-1s function by imitating hormones that control several 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 may be an efficient means of reducing your weight when combined with other lifestyle modifications and taken under the guidance of a healthcare practitioner.
Most of these drugs are verified to be used by adults with obesity or overweight with at least one illness associated with weight, such as high blood pressure, type 2 diabetes, or high cholesterol.
These medications are made for those who have tried diets and other lifestyle changes without success in losing weight.
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.
Remember that not everyone is eligible for weight-loss drugs, including pregnant women, people with certain medical conditions, or on particular medications.
At our clinic, we advise whether you would be a candidate for a prescription depending on your personal goals, medical history, and current health state.
What If Insurance Won’t Cover My Weight Loss Medication?
If Blue Cross Blue Shield does not cover your medication, you may get other options for more affordable medication coverage. Unfortunately, medications like WeGovy and Ozempic will typically still 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.
The specialists in NP2GO Clinic have a 90% success record with patients and will collaborate with you to develop the ideal weight-loss strategy based on your unique body and lifestyle.
Weight Care Management Via NP2GO Clinic
At NP2GO Clinic, we are determined to offer the best weight management solutions, from at-home lab testing to virtual care visits. With our weight care solutions, NP2GO’s clinical care team helps to identify the best medication for you based on your insurance coverage and health needs.
We understand that various biological features, lifestyle or life experiences, and conditions influence each person’s health. We will consider where you are right now, examine your long-term goals, and address biological issues like insulin resistance to decide which weight loss medication and techniques will benefit you the most.
Whether you meet with us in-office or virtually, we’ll ensure you have a friendly and judgment-free experience with a team that wants to see you succeed. Book an appointment with us today for comprehensive weight care management.