Blue Cross Blue Shield of Michigan and Blue Care Network GLP-1 Update

On June 6, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network announced they plan to change the criteria for coverage of GLP-1 obesity drugs, including Wegovy, Saxenda and Zepbound effective August 1, 2024. Additionally, the Blues will no longer cover these GLP-1 drugs for weight loss starting January 1, 2025, or on a group’s renewal date.

GLP-1 is a hormone in your small intestine. The drug triggers the release of insulin from the pancreas as well as preventing glucose from entering the bloodstream. GLP-1 drugs have been found to also slow down digestion and increase the sensation of a full stomach — making it an effective drug for obese patients needing to lose weight.

Criteria changing in August

All current prior authorizations for fully insured Blue Cross and BCN members taking Saxenda, Wegovy or Zepbound for weight loss will expire July 31, 2024. New prior authorization requirements must be met, starting Aug. 1, for these medications to be covered.

The new requirements are:

• Members must be 18 or older.
• Members must have a body mass index of 35 or higher.
• Medication must be prescribed by a primary care provider or another provider who has an established relationship with the member and who has seen the member in person.
• The prescribing doctor must document the member’s current baseline weight (within 30 days).
• The prescribing doctor must document the member’s active participation for a minimum of six months in a lifestyle modification program (working with a coach, tracking food and exercising).
• The member must enroll and participate in the Teladoc® Health weight management program.  
• This medication can’t be used in combination with other weight loss products.
• This medication can’t be used in combination with other products containing glucagon-like peptide-agonists.
• Saxenda, Wegovy and Zepbound won’t be covered for members who have Type 2 diabetes.

Starting Aug. 1, fully insured members will need to contact their prescribing doctors to request prior authorization for Saxenda, Wegovy and Zepbound. If the new coverage requirements aren’t met, members will no longer qualify for coverage. The Blues plans to notify affected members about this change.

Additional changes in 2025  

Beginning Jan. 1, or on a group’s health coverage renewal date, the Blues will no longer cover prescriptions for GLP-1 drugs — including Saxenda, Wegovy and Zepbound — for weight loss for fully insured members. If members continue to use these medications in 2025, they’ll be responsible for the full cost.  

Self-funded groups will continue to have options if they wish to include these drugs in their benefit programs.