We’re changing prior authorization requirements for some weight loss drugs

Beginning Sept. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will amend prior authorization coverage criteria for the brand-name weight loss medications listed below for commercial members.

• Contrave^®
• Qsymia^®
• Saxenda^®
• Wegovy^®
• Xenical^®

For certain members, weight loss drugs are excluded under the pharmacy benefit.

Prior authorization and renewal criteria changes

Starting Sept. 1, we’ll shorten the initial prior authorization approval duration to four months from 12 months for commercial Blue Cross and BCN members who initiate one of these drug therapies for the first time. The duration of subsequent prior authorization renewals following initial prior authorization approval will remain unchanged and valid for 12 months for members who meet renewal requirements. 

We’ll also amend the renewal criteria for these weight loss drugs. Health care providers will be required to attest that the member is actively engaged in appropriate lifestyle modifications in conjunction with weight loss therapy for continuation of coverage after the initial prior authorization expires, and for each renewal request thereafter.
 
For a list of prior authorization and renewal requirements for pharmacy benefit drugs, refer to our prior authorization and step therapy document at bcbsm.com/rxinfo.

Reasons for these changes

Weight loss drug therapy is highly effective when used in conjunction with appropriate lifestyle interventions, including a balanced healthy diet and exercise. Providers should follow up with patients at regular intervals after initiating weight loss pharmacotherapy to make sure they’re continuing to engage in appropriate lifestyle modifications for optimal weight loss results.

Documentation of appropriate lifestyle modifications

Providers must attest through electronic prior authorization, or ePA, that the patient has provided them with documentation to show that they’re participating in appropriate lifestyle modifications. Here are some examples of documentation and lifestyle modifications:

• Patient documentation of lifestyle modifications may include recent food logs, exercise logs or receipts to show engagement in a formal weight loss modification program.
• Appropriate lifestyle modifications may include member participation in a formal lifestyle modification program or participation in an appropriate lifestyle modification treatment plan (healthy diet and exercise) under the supervision of their provider.

Member eligibility

Not all members have weight loss drugs covered under their pharmacy benefit. Providers should determine if members are eligible before prescribing weight loss drug therapy.

Providers can call the Provider Inquiry automated response system at 1-800-344-8525 to verify eligibility for members with Blue Cross or BCN commercial coverage.