June 28, 2024
Some of our members have a new pharmacy benefit for GLP-1 drugs that are indicated for Type 2 diabetes and weight management. This new benefit may include the following drug products: Adlyxin, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Saxenda, Trulicity, Victoza, Wegovy, and Zepbound.*
What’s changing?
As of April 1, 2024, an optional GLP-1 New to Therapy pharmacy benefit program became available for some employer groups with Prime Therapeutics. This new program aims to reduce drug waste and cost of care associated with beginning GLP-1 drug therapy. GLP-1 New to Therapy also may help members use the medication as intended, based on FDA labeling, until they find their maintenance dosage.
The program limits initial fill(s) to 30 days for members who are new to GLP-1 drug therapy or have no claims history within the past 120 days. After the initial fill(s), members may be eligible for up to a 90-day supply, per their pharmacy benefits. The 30-day supply limit may continue to apply after the first fill if the member moves to a new dosing strength or changes to a different GLP-1 medication. The program doesn’t apply to members currently taking a GLP-1 drug on a maintenance dosage.
GLP-1 New to Therapy categories and medications included may vary according to employer group selections. Program details and applicable prior authorization requirements are based on the member’s pharmacy benefits.
Who’s affected?
This program is one example of an employer group option that may apply to some of our commercial members. Always check eligibility and benefits first for each member at every visit. This step will confirm membership and other details, such as prior authorization requirements and utilization management vendors, if applicable.
- For services/drugs under the member’s medical benefit, check eligibility and benefits electronically via Availity® Essentials or your preferred vendor prior to rendering care.
- For drugs under the member’s pharmacy benefit, call the number on the member’s ID card before prescribing.
If your patients have questions, they can call the number on their member ID card for BCBSIL, log on to Blue Access for MembersSM, or visit MyPrime.com.
*This list is subject to change. Trademarks are the property of their respective owners.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Regardless of benefits, the final decision about any medication is between the member and their health care provider. If you have any questions, call the number on the member's ID card.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. BCBSIL, as well as other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC. MyPrime.com is an online resource offered by Prime Therapeutics. Availity is a trademark of Availity, LLC., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products or services they offer.