Reply to Federal BCBS tier exception for wegovy?

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[quote=Anonymous][quote=Anonymous][quote=Anonymous]I don’t think the tier exception changes the price. [/quote]

I think it cuts the price in half?[/quote]

The tier absolutely changes the price that you will pay out of pocket, but by how much depends on whether your plan is Basic or Standard. I have Standard, so that is the only pricing I'm familiar with. On Standard, with Wegovy now being a Tier 3 drug in 2025, the amount the patient pays is 50% coinsurance -- so the patient pays 50% of the allowed retail price. Which is about $640, according the BCBS drug cost tool.

I was fortunate enough to get a tier exception, which knocks the drug down to tier 2 for me, so I pay a lesser price -- I've been paying $160 or so dollars per month. Not sure why this is, there may be a manufacturers coupon or other behind-the-scenes discounts involved or something, because tier 2 drugs are 30% coinsurance. Which would be about $425 or so.

The pricing gets really weird when you see the application of the manufacturer coupons and there are PBR discounts sometimes applied behind the scenes. So often, with fancy new expensive drugs, you will get to the pharmacy and see that your cost is less than your 50% or 30% coinsurance. We don't question it, because hey -- who doesn't want to see a price of $160 when they thought it would be $425? The pricing gets very complicated, and it is all designed to get more people to purchase the drug. It's not a transparent system. You can be getting your medication for $X price and then suddenly be shocked when 6 months down the line the price goes way up -- because there was some discount being applied that no longer is. But now you have been on the med for months, and it is working for you, so you are going to find a way to pay for it.

Sorry if this is way more than anyone wanted to know, lol. But I've been a bit obsessed with this stuff. [/quote]

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