Hello all. I'd appreciate guidance here, as I'm pretty stressed out by all of this. I plan to call Monday, but have read things about WellDyne giving conflicting and untrue info, so I'd really like to get a read here first. I also work in healthcare and know insurance reps will sometimes say things to get you off the the phone.
I received this letter from WellDyne, the company that manages my parents workplace Blue Cross PPO Rx benefits, on Friday. For reference, here is the webpage including the full Rx formulary and plan information.
I have been on Wegovy since 03/2023, and have lost over 60 lbs. I struggle with chronic familial obesity and PCOS, so I was quickly approved and pre-authorized. I recently was prescribed 2.4mg and received it. I also received the letter. I understand that a formulary "does not necessarily guarantee coverage", but I have a PA through the next year and a health plan document that I do not feel says what they're saying it does.
The quoted text in their letter is in reference to the full plan documents exclusions section stating that SKIN REMOVAL post bariatric surgery, not surgery, is excluded, and it goes on to say "see also the plans coverage on weight reduction drugs". Considering this wording, and the fact that the drug is blatantly in the formulary and I was given it for seven months, I feel like this doesn't make any sense. I plan to call on Monday and see if I can get more info.
I'd really appreciate anyone else's take on this wording & the exclusions portion of the document in question. Ive read it up and down, and I do not feel that the weight reduction drugs are mentioned in the same way they are mentioning the other items.
submitted by /u/Canolioli