Changes coming for select weight loss drugs for some commercial members

Blue Cross Blue Shield of Michigan and Blue Care Network are changing how we approach coverage of glucagon-like peptide-1 receptor agonist, known as GLP-1, drugs indicated for weight loss for our fully insured large group commercial members. These drugs include:

• Saxenda^® (liraglutide)
• Wegovy^® (semaglutide) 
• Zepbound^® (tirzepatide) 

Here’s what will change:

• Aug. 1, 2024 – Current prior authorizations for these drugs will end at midnight July 31. New prior authorization requests 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 new prescriptions 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, their new prior authorizations will end before their renewal dates, instead of Dec. 31.
• Jan. 1, 2025 – Coverage for GLP-1 weight loss drugs for fully insured large group commercial members will end Jan. 1, 2025. For members with a plan renewal date other than Jan. 1, the coverage will end on the renewal date.

We’re notifying members affected by these changes and their prescribers.

We’re changing prior authorization criteria

For dates of service from Aug. 1 through Dec. 31, 2024, Saxenda, Wegovy and Zepbound will have new prior authorization criteria for fully insured large group commercial members.

The new criteria will not apply to MESSA group members. In addition, self-funded groups that cover GLP-1 drugs for weight loss may continue using their current prior authorization criteria.

All current authorizations for these medications for fully insured large group commercial members will expire July 31, 2024, and the following new criteria will apply:

• 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 health care 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 of six months before the prior authorization request. The prescriber will no longer be able to simply attest to a member’s participation. Without this documentation, the request will be denied.
• The member must enroll and participate in the Teladoc^® Health program for weight management. This program, at no cost to eligible members, 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

For more information on how to submit a prior authorization electronically:

1. Go to ereferrals.bcbsm.com.
2. Select Blue Cross for PPO members or BCN for HMO members.
3. Click on Pharmacy Benefit Drugs in the left navigation.
4. See the section, “How to submit an electronic prior authorization, or ePA, request.”

What you need to do

If you have Blue Cross or BCN commercial members with a current prior authorization for Saxenda, Wegovy or Zepbound, ask the members if they are affected by this change. Members will know they’re affected if they receive letters from Blue Cross and BCN. Members can also check their Blue Cross member accounts or call the Customer Service number on their ID cards.

If a member is affected, you’ll need to submit a new prior authorization request following the new requirements for dates of service beginning Aug. 1, 2024. Based on the new requirements, the member may require a new prescription. If the new coverage requirements aren’t met, or the documentation noted above is not included in the prior authorization request, the member will no longer qualify for coverage.

We’re changing coverage

Beginning Jan. 1, 2025, Blue Cross and BCN will no longer cover any GLP-1 drug for weight loss for fully insured large group commercial members. For group members with a plan renewal date other than Jan. 1, this change will go into effect on the renewal date.

This applies to all GLP-1 weight loss drugs, including Saxenda, Wegovy and Zepbound.

If you keep a member who is affected by this change on a GLP-1 drug for weight loss, that member will be responsible for the full cost of the drug.

We’ll update our drug criteria documents

The following documents will be updated to reflect these changes as they occur:

• Blue Cross PPO and BCN HMO prior authorization and step therapy coverage criteria
• Blue Cross PPO and BCN HMO prior authorization and step therapy coverage criteria for the Preferred Drug List

Why Blue Cross and BCN are making these changes

We’re making these changes in part because research has shown that a person’s chance of success in losing weight and maintaining that weight loss is greatly improved when medication is paired with lifestyle changes, including diet and exercise.^1,2 This is why we’re requiring that members on Saxenda, Wegovy or Zepbound participate in the weight management program through Teladoc Health.

In addition, prescription medications need to be effective as well as safe. Data published by the Blue Cross Blue Shield Association in May 2024 shows that most patients aren’t staying on GLP-1 drugs for weight loss long enough to see a benefit.³ Due to the high cost of these drugs and supply considerations, we want to ensure they are used for the most appropriate patients who can achieve clinical benefits. Additional research is needed to understand whether GLP-1 medications lead to lower medical costs in the long term.

Questions?

If you have questions, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

See the additional article in this issue about a change to coverage criteria for other GLP-1 drugs for Medicare Advantage members.

¹Jensen, S. B., Blond, M. B., Sandsdal, R. M., Olsen, L. M., Juhl, C. R., Lundgren, J. R., Janus, C., Stallknecht, B. M., Holst, J. J., Madsbad, S., & Torekov, S. S. (2024). Healthy weight loss maintenance with exercise, GLP-1 receptor agonist, or both combined followed by one year without treatment: A post-treatment analysis of a randomised placebo-controlled trial.**  eClinicalMedicine, 69, 102475.

²Dalle Grave, R. (2024). The benefit of healthy lifestyle in the era of new medications to treat obesity.**  Diabetes, Metabolic Syndrome and Obesity, 17, 227-230.

³Blue Cross Blue Shield Association, Blue Health Intelligence Issue Brief (May 2024). Real-World Trends in GLP-1 Treatment Persistence and Prescribing for Weight Management.** Retrieved from https://www.bcbs.com/sites/default/files/BHI_Issue_Brief_GLP1_Trends.pdf**

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.