Ingabe i-Blue Cross Ikhava i-Zepbound?

Ukuhlanganiswa kwe-BCBS kwe-Zepbound kuyahlukahluka kakhulu kuye ngohlelo lwakho oluthile, isifundazwe sakho, kanye nokuthi kungani imithi yabelwa. Izinhlelo eziningi ezijwayelekile ze-BCBS azihlanganisi i-Zepbound ngokwejwayelekile ukuze kwehliswe isisindo. Ezinye izinhlelo ziyakuhlanganisa ngemvume yangaphambili, futhi izinhlelo zabaqashi abazihlinzekayo zinomuvivinyo omkhulu. Ake sihambe ngokuthi konke kusebenza kanjani.

Kungani Ukuhlanganiswa Kuhlukahluka Kanjalo Nge-BCBS?

Ngokungafani nabanye abaningi abahlinzeki bezomshuwalense, i-Blue Cross Blue Shield ayiyona inkampani eyodwa. Isebenza njengenethiwekhi yezinhlangano zesifundazwe ezizimele kulo lonke izwe. I-BCBS yaseMichigan inezinqubomgomo ezahlukene kune-BCBS yaseTennessee, okuhluke kune-BCBS yase-Illinois.

Indlunkulu ngayinye ibeka ifomular yayo (uhlu lwemithi eyihlanganisayo) kanye nemithetho yayo yokugunyazwa kwangaphambili. Ngaphezu kwalokho, abaqashi abazihlinzekayo izinhlelo zabo zezempilo nge-BCBS bangakhetha ukufaka noma ukukhipha imithi yokulawula isisindo ngokuphelele. Lokhu kusho ukuthi abantu ababili esifundazweni esifanayo abanamakhadi e-BCBS bangathola izimpendulo ezahlukene kakhulu mayelana nokuhlanganiswa kwe-Zepbound.

Yiziphi Izinhlelo Ze-BCBS Ezikulungele Ukuhlanganisa i-Zepbound?

Lapho kuhlolwa amafomula ezinhlangano eziningi ze-BCBS, izandla kuphela ezibala i-Zepbound ohlwini lwazo lwemithi. Nansi imininingwane ejwayelekile yokuthi izinhlobo ezahlukene zezinhlelo ziyibhekana kanjani.

Izinhlelo zabaqashi abazihlinzekayo yizo ezikulungele ukuhlanganisa i-Zepbound. Kulokhu kuhlangatshezelwa, umqashi wakho wenziwa izinqumo zokuhlanganisa, futhi i-BCBS ivele iphathe izinzuzo. Abanye abaqashi bakhethe ukufaka imithi ye-GLP 1 yokulawula isisindo njengengxenye yephakheji yabo yezinzuzo. Uma usebenza enkampanini enkulu, kufanele ubuyele emnyangweni wakho we-HR ngokuqondile.

Izinhlelo zezentengiselwano ezihlinzekwa ngokugcwele yilapho kunemikhawulo emikhulu kakhulu ivela khona. Izinhlangano eziningana ze-BCBS ziye zakhipha imithi ye-GLP 1 yokudla ngesisindo emifomula yazo. I-BCBS yaseMichigan yeke ukuhlanganisa i-Zepbound, i-Wegovy, kanye ne-Saxenda kumalungu ezinkampani ezinkulu ezigcwele izinzuzo kusukela ngo-Januwari 1, 2025. I-BCBS yaseMassachusetts ibilokhu imemezele izinto ezifanayo kusukela ngo-Januwari 1, 2026. I-BCBS yaseNorth Dakota nayo yenze izinguquko ekuhlanganisweni kwemithi yokudla ngesisindo ngo-2026, ithi izindleko ziya ngokuya ziba phezulu.

Izinhlelo zeFederal Employee Program (FEP) zinamafomula azo. Njengamanje, i-Zepbound ingafuna ukwenziwa kwenkululeko yefomula ukuze ihlanganiswe. Uma igunyaziwe, ingena ku-Tier 3 (engakhethwa) ezinhlotsheni eziningi zezinhlelo ze-FEP.

Izinhlelo ze-Medicare ne-Medicaid BCBS. Izinhlelo eziningi ze-BCBS Medicare azihlanganisi i-Zepbound ukuze kwehliswe isisindo. Ukuhlanganiswa kungase kudingeke uma umuthi ubelwa ukuvimbela i-sleep apnea. Ukuhlanganiswa kwe-BCBS Medicaid kuyahlukahluka ngesifundazwe. Ezinye izinhlelo ze-Medicaid zezifundazwe zingahlanganisa i-Zepbound ukuze kulungiswe i-sleep apnea kodwa zingayihlangani ukuze kwehliswe isisindo.

Yini I-BCBS Eyidingayo Ukuze Kuhlanganiswe i-Zepbound?

Kwezinhlelo ze-BCBS ezihlanganisa i-Zepbound, ukugunyazwa kwangaphambili kucelwa cishe njalo. Umhlinzeki wakho wezempilo uzodinga ukuthumela imibhalo ku-BCBS efakazela ukuthi imithi ibalulekile ngokwezokwelapha.

Izidingo ezijwayelekile zihlanganisa i-BMI eyakameliweyo engu-30 noma ngaphezulu, noma i-BMI engu-27 noma ngaphezulu enesimo esisodwa esihlobene nesisindo njengoshinga wesifuba sohlobo 2, umfutho wegazi ophakeme, noma i-sleep apnea evimbayo. Izinhlelo eziningi zidinga nobufakazi bokuthi ubambe iqhaza ohlelweni oluqinile lokulawula isisindo oluhlanganisa ukudla, ukuzivocavoca, kanye noshintsho lokuziphatha isikhathi esiyizinyanga eziyisithupha okungenani.

Ezinye izinhlelo zidinga ne-step therapy. Lokhu kusho ukuzama nokwehluleka kweminye imithi ehlangene (njenge-Wegovy, Saxenda, Qsymia, noma i-orlistat) ngaphambi kokuthi i-BCBS igunyaze i-Zepbound. Futhi ukuze ugcine ukuhlanganiswa okuqhubekayo, ezinye izinhlelo zidinga imibhalo yokuthi uyaqhubeka nokunciphisa isisindo ngenkathi uphuza umuthi.

Kwenzekani Uma I-BCBS Yenqaba Ukuhlanganiswa Kwakho Kwe-Zepbound?

Ukunqatshelwa akufanele kube ukuphela kwempendulo. Unelungelo lomthetho lokudlulisa isikhalazo, futhi amazinga okuphumelela angcono kunalokho abantu abaningi abacabanga. Ukuhlaziya kuthole ukuthi ngaphezu kuka-80% wokwenqatshwa kokugunyazwa kwangaphambili okudlulisiwe kwahlehliswa lapho kubhalwe kahle. Nokho, ingaphansi kuka-10% weziguli ezike zidlulise isikhalazo.

Uma wenqatshwa, qala ngokubuyekeza incwadi yakho yokwenqatshwa ngokucophelela. Izichaza isizathu futhi ibeka izinketho zakho zokudlulisa isikhalazo. Sebenza nomhlinzeki wakho wezempilo ukuze uqoqe imibhalo eyisekelayo, okuhlanganisa amarekhodi ezokwelapha, umlando we-BMI, imiphumela yelabh, namazwana ngemizamo yangaphambili yokunciphisa isisindo. Uma i-Zepbound ikhubekiswe kwi-formulary yakho ngokuphelele, ungathumela isicelo sokwenziwa kwenkululeko ye-formulary uchaza ukuthi kungani izindlela ezihlangene zingakulungele.

Yiziphi Izinketho Zakho Uma I-BCBS Ingenakuhlangana Nayo i-Zepbound?

Ngisho nangaphandle kokuhlanganiswa, kunezindlela zokwenza i-Zepbound ibe nentengo ephansi.

Ikhadi Lokonga Le-Zepbound elivela ku-Eli Lilly linganciphisa izindleko zibe phansi njengo-$25 ngenyanga uma uhlelo lwakho lokuthengiselana luhlanganisa i-Zepbound. Uma uhlelo lwakho lungayihlangani, ikhadi lokonga linganciphisa intengo ibe cishe u-$499 ngenyanga nge-pen eyodwa. I-LillyDirect inikeza izikhwama ze-Zepbound ezinezingqamuzana eziyodwa ngentengo yemali eqala cishe ku-$299 kuye ku-$449 ngenyanga kuye ngomthamo. Lokhu kudlula umshuwalense ngokuphelele futhi kuyatholakala kunoma ubani onephrofeshiyoni.

I-BCBS futhi ihlanganisa imithi eyi-alternative yokulawula isisindo okungafanele ikufanele ukuxoxisana nomhlinzeki wakho, okuhlanganisa i-Wegovy, i-Saxenda, i-Qsymia, kanye ne-orlistat.

Indlela Yokuhlola Ukuhlanganiswa Kwakho Okuthile Kw-BCBS

Njengoba ukuhlanganiswa kuhluka kakhulu, ukuhlola uhlelo lwakho oluthile kubalulekile. Ngena ngemvume ku-portal yakho yelungu le-BCBS bese usebenzisa ithuluzi lokubheka imithi ukuze useshele i-Zepbound. Ungaphinda ushaye inombolo yamalungu encwadi yakho yomshwalense bese ubuza ukuthi i-Zepbound ikhona yini kwi-formulary yakho nokuthi yimaphi izidingo zokugunyazwa kwangaphambili ezisebenza. Uma unohlelo oluxhaswa ngumqashi, buza ku-HR mayelana nokuthi inkampani yakho ihlanganisa yini imithi yokulawula isisindo.

Isiphetho

Ezinhlelweni eziningi ezijwayelekile, ukuhlanganiswa ukuze kwehliswe isisindo kukhawulelwe noma kukhishwe. Kodwa izinhlelo zabaqashi abazihlinzekayo, izinhlangano zesifundazwe ezithile, kanye nemithi yokuvimbela i-sleep apnea kungase kuvule iminyango. Uma uvinjelwe, ukudlulisa isikhalazo ngemibhalo eqinile kufanele kube umzamo. Futhi uma ukuhlanganiswa kungatholakali, ikhadi lokonga kanye ne-LillyDirect zinikeza izindlela zangempela zokunciphisa izindleko.

Isitatimende: Lokhu okuqukethwe kungokwemininingwane kuphela futhi akufanele kufake iseluleko sezokwelapha esisezingeni eliphezulu noma somshwalense. Izinqubomgomo zokuhlanganisa zishintsha njalo. Njalo vumela izinzuzo zakho ngokuqondile nohlelo lwakho lwe-BCBS futhi uxoxe nomhlinzeki wezempilo ofanelekayo ngezinqumo zokwelashwa.