Blue Cross patients navigate changes to weight loss insurance coverage

A week after Blue Cross Blue Shield insurance coverage changes took effect, patients using weight loss drugs in Michigan are navigating the impact.

Twenty-seven-year-old Payton Scott has struggled with polycystic ovary syndrome, or PCOS, for most of her life.

After using the drug Metformin and experiencing painful symptoms, Scott and her doctor decided to switch her to Ozempic.

“Once I switched to that Ozempic, I had no symptoms. Everything was great,” Scott said.

However, she's on her last box after being notified by her pharmacist that she needed another pre-authorization.

“It sucks. It really does hurt me because like I said, doing the shot once a week was a lot easier — no side effects verses this Metformin, I know exactly what I’m going to be going back to the four pills a day," Scott said.

Dr. James Grant, chief medical officer with Blue Cross Blue Shield of Michigan, says the decision was not made lightly.

"We’ve been having to talk about it for at least the past six to 10 months and we really struggled with it,” Grant said.

Hear more from Grant on the coverage decision in the video below:

Grant says the decision mainly came down to cost.

“The prices of these drugs are really, really high. The drug companies, we’re talking over a thousand dollars a month," Grant said. "And at the end of the day, we have to be competitive, and when your competitors aren’t covering them, it really makes it tough for you to be able to cover it when you’re trying to make health care affordable for everybody.”

He added that so far this year, the company has spent $100 million on claims for the drugs, which have increased in popularity recently.

Scott is one of around 9,500 members impacted by the changes. She is particularly in need of the medicine to help with insulin regulation, which impacts fertility.

"I feel awful for anyone whose in the same boat as I am,” Scott said. "I just hope that they can figure it out soon.”

We reached out to the community on Facebook about the coverage change. You can see responses by clicking the post below: