FEP coverage for 2026, Zepbound and Wegovy

[Anonymous]

Are these numbers even out yet? Can anyone understand what standard option FEP drug plan will be paying for these drugs in 2026? I’m finding it very confusing with terms like tier exemption and coupons and whether we are eligible.
Please talk to me like I’m a child

[Anonymous]

It is complicated.

Wegovy is on the fep bcbs standard formulary for 2026 as a tier 3 drug which means that you pay 50% coinsurance for it. That means that you will pay half of the retail price for it. Retail prices on these drugs are in flux and will likely go down in 2026, but the amount you pay for a tier 3 drug (a non-preferred brand name drug), which is what Wegovy is according to the formulary, will be half of the retail price whatever that price may be. A tier exception is when you ask bcbs to give you an exception to the tier structure -- specifically, you ask them to allow you the tier 3 drug at the tier 2 coinsurance. Tier 2 (preferred brand name drugs) coinsurance is 30 percent, so you only pay 30 percent of the retail price. I actually have a tier exception, and only have to pay 30 percent coinsurance for my Wegovy, but I can't take any of the cheaper weight loss drugs on the formulary for medical reasons and my doctor filed a tier exception request documenting that. So that is what a tier exception is -- you ask BCBS to give you a tier 3 (nonpreferred brand name) drug at the tier 2 (preferred brand name drug) coinsurance/price. Very hard to get unless you can't take any of the cheaper weight loss meds (and there are many).

So, let's talk about coupons. Drug manufacturers often provide coupons to consumers to offset the price of expensive on-patent drugs. They don't really do this out of the goodness of their hearts, it is a marketing technique to get you to take their drug. At any rate, Novo Nordisk has a coupon for patients with private insurance that significantly reduces the price of Wegovy. For most of us, it brings the cost all the way down to $25 for a month's supply. Which is amazing. There is a limit to this though -- Novo Nordisk's coupon is limited to six fills (or at least it was when I first went on Wegovy). So after that, your cost is going to go way up. They hook you in, lol.

Complicating things even more is that there are other behind the scenes discounts that sometimes come into play that your pharmacist might not even be able to explain. Big pharma and the business of selling on-patent drugs is what I would call downright shady. But people don't question it when they pay less than they expected to, because hey -- who doesn't want a discount worth hundreds?

[Anonymous]

Anonymous wrote:It is complicated.

Wegovy is on the fep bcbs standard formulary for 2026 as a tier 3 drug which means that you pay 50% coinsurance for it. That means that you will pay half of the retail price for it. Retail prices on these drugs are in flux and will likely go down in 2026, but the amount you pay for a tier 3 drug (a non-preferred brand name drug), which is what Wegovy is according to the formulary, will be half of the retail price whatever that price may be. A tier exception is when you ask bcbs to give you an exception to the tier structure -- specifically, you ask them to allow you the tier 3 drug at the tier 2 coinsurance. Tier 2 (preferred brand name drugs) coinsurance is 30 percent, so you only pay 30 percent of the retail price. I actually have a tier exception, and only have to pay 30 percent coinsurance for my Wegovy, but I can't take any of the cheaper weight loss drugs on the formulary for medical reasons and my doctor filed a tier exception request documenting that. So that is what a tier exception is -- you ask BCBS to give you a tier 3 (nonpreferred brand name) drug at the tier 2 (preferred brand name drug) coinsurance/price. Very hard to get unless you can't take any of the cheaper weight loss meds (and there are many).

So, let's talk about coupons. Drug manufacturers often provide coupons to consumers to offset the price of expensive on-patent drugs. They don't really do this out of the goodness of their hearts, it is a marketing technique to get you to take their drug. At any rate, Novo Nordisk has a coupon for patients with private insurance that significantly reduces the price of Wegovy. For most of us, it brings the cost all the way down to $25 for a month's supply. Which is amazing. There is a limit to this though -- Novo Nordisk's coupon is limited to six fills (or at least it was when I first went on Wegovy). So after that, your cost is going to go way up. They hook you in, lol.

Complicating things even more is that there are other behind the scenes discounts that sometimes come into play that your pharmacist might not even be able to explain. Big pharma and the business of selling on-patent drugs is what I would call downright shady. But people don't question it when they pay less than they expected to, because hey -- who doesn't want a discount worth hundreds?

PP again. I'm not on Zepbound, so haven't looked into it, but as I understand it, it is not covered at all on bcbs fep standard.

[Anonymous]

This is great information. I’m on Zepbound and my husband is on Wegovy. I’m paying 50% cost which is something like $350 mo.
The problem I bump up against is pharmacies thinking I have government sponsored insurance when it is private insurance.
Thanks for taking the time to explain this.

[Anonymous]

I don’t think Zepbound is covered at all. I currently pay $25 copay per Ozempic pen (diabetes) and hope it stays that way.