Reply to MD Obamacare/ACA CareFirst BCBS HMO

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Reply to "MD Obamacare/ACA CareFirst BCBS HMO - GLP coverage?"

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[quote=Anonymous]This is an insurance coverage question.  Since every insurance policy has different coverage parameters, please answer this only if you currently have the CareFirst/BCBS HMO Point of Access Gold $1000 plan purchased on the Maryland ACA health insurance exchange (aka Obamacare).

If you have this plan, were you able to get a GLP covered? If so, which one - semaglutide or tirzepatide or something else?  If so, what process - did your doctor ask for prior authorization? Were you initially denied and then did you appeal successfully?  What medical reasons were provided - what was your BMI? Did you have other “risk factors” like diabetes, high cholesterol or sleep apnea. Did you ah e to show that you had tried other treatments and, if so, which ones?

I called and the customer service agent told me that this plan “does not cover these medications because they are primarily for weight loss” even though I said they were being prescribed instead of statin and sleep apnea treatment. The agent warned me that pre-authorization would be denied and appeal would be unsuccessful.  I’m trying to judge whether it’s worth it to ask my PCP to jump through more hoops.

Again, please only answer these questions if you have this specific insurance.   [/quote]

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