Any Feds on Wegovy or Saxenda?

[Anonymous]

I have UHC feds and they don’t seem to cover Wegovy or Saxenda which is contrary to the guidance OPM gave them last year where they cannot exclude anti obesity meds from coverage. Anyone with UHC feds able to get Wegovy or Saxenda approved? If yes, what steps did you have to take?

[Anonymous]

A little different but GEHA is covering Ozempic, if that’s an option for you.

[Anonymous]

Fed guidance doesn't say they can't exempt them. It says they have to provide "adequate coverage" for anti-obesity therapies...and a payor will find a lot of ways to provide "adequate coverage" that aren't what you think they should be.

I would broadly expect that if you aren't clearly within the prescribing guidelines you won't be covered. Meaning you won't get coverage for wanting to lose 20-30lbs...you will have to meet the labeling guidelines for BMI or medical conditions exacerbated by BMI. These drugs are expensive and while there are definitely value arguments to made, insurers will try to find a lot of reasons to not cover them if they can.

[Anonymous]

Anonymous wrote:Fed guidance doesn't say they can't exempt them. It says they have to provide "adequate coverage" for anti-obesity therapies...and a payor will find a lot of ways to provide "adequate coverage" that aren't what you think they should be.

I would broadly expect that if you aren't clearly within the prescribing guidelines you won't be covered. Meaning you won't get coverage for wanting to lose 20-30lbs...you will have to meet the labeling guidelines for BMI or medical conditions exacerbated by BMI. These drugs are expensive and while there are definitely value arguments to made, insurers will try to find a lot of reasons to not cover them if they can.

Sorry I should have clarified that the Fed guidance says plans can't exempt the entire category of anti-obesity meds...but it does not provide that they have to provide coverage for these specific drugs.

[Anonymous]

So Optum Rx UHC pharmacy benefit manager has no anti obesity meds on the formulary, not Contrave, not phentermine, nothing. If you look at page 26 of the guidance https://www.opm.gov/healthcare-insurance/healthcare/carriers/2022/2022-04.pdf. if plans do not cover Saxenda or Wegovy under the formulary they need to describe how they will cover them using medical necessity. Calling UHC and Optum they state that they will not cover it under any medical criteria. I am wondering if this is an issue that needs to be brought up with OPM.

[Anonymous]

I'm so confused. I'm a new fed, what plan should I choose to get ozempic or wegovy covered? Or at least best chances? I'm obese but not diabetic. Ozempic has been working wonders for me but I can't keep paying out of pocket forever.

[Anonymous]

Anonymous wrote:I'm so confused. I'm a new fed, what plan should I choose to get ozempic or wegovy covered? Or at least best chances? I'm obese but not diabetic. Ozempic has been working wonders for me but I can't keep paying out of pocket forever.

Definitely not UHC based on what I am going through. Click in each individual plan and check their formulary.

[Anonymous]

BCBS basic covers wegovy with a prior authorization

[Anonymous]

This is the clarified guidance from OPM the other link did not work https://www.opm.gov/healthcare-insurance/healthcare/carriers/2022/2022-04.pdf

[Anonymous]

Anonymous wrote:BCBS basic covers wegovy with a prior authorization

I looked at this yesterday. To qualify for the PA you need to either have a BMI over 30 or a BMI over 27 and a risk factor.

[Anonymous]

Anonymous wrote:

Anonymous wrote:BCBS basic covers wegovy with a prior authorization

I looked at this yesterday. To qualify for the PA you need to either have a BMI over 30 or a BMI over 27 and a risk factor.

That makes sense, that’s the criteria to qualify for the drug in the indicative section of the package insert. If your BMI is 27+ you’ll probably have some dyslipidemia or something that will help you qualify

[Anonymous]

Anonymous wrote:BCBS basic covers wegovy with a prior authorization

What is the copay? Thanks.

[Anonymous]

Anonymous wrote:BCBS basic covers wegovy with a prior authorization

Do you know if BCBS basic covers Mounjaro as well with a prior authorization?

[Anonymous]

Anyone other Kaiser have any luck?

And are these meds ultimately things you have to take forever or just to get you to a healthier weight?

[Anonymous]

Anonymous wrote:Anyone other Kaiser have any luck?

And are these meds ultimately things you have to take forever or just to get you to a healthier weight?

Whatever is preventing you from losing weight now will come back after you go off the medication. I don’t know why people think this is a temporary medication. If you need a drug to help you lose weight why wouldn’t you need it to maintain the lower weight?