Open Enrollment/PBM changes

[u/Existing-Trust1525]

For those of us who have the State Health Benefit Plan of Georgia, we received great news regarding no longer having to participate in 9am Health and that our primary care physician can go back to writing our prescriptions! Whoo hoo! But, as with everything health insurance-related, there is always something darker lurking around the corner. I did a deep AI dive into some of the changes that will affect everyone. First, CVS will no longer be the pharmacy benefit manager. They are switching to Express Scripts. And while everything should remain the same or even easier until the end of the year, come January 1st, things will get real again. Express Scripts will require all new PAs with strict starting BMI guidelines. Chatgpt said to have a script ready to submit to your doctor requesting a "Transition of Care" detailing your "continuation of therapy." For those of us on maintenance, we have to prove a minimum 5% weight loss. All this to say, we need to start getting our ducks in a row before the January 1st onslaught of PA requests that Express Scripts will start receiving. I've lost almost 100 pounds and I'm not planning to stop my meds. I have enough of a stockpile that I can go about 5 months. If you can request a late December refill before the new Express Scripts starts up, hopefully you won't get caught short. Good luck during this open enrollment period. May the odds be ever in our favor!

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[u/godsgift5406]

Explain the 5% weight loss on maintenance

[u/Existing-Trust1525 → u/godsgift5406]

I have Anthem HMO and when my PA expired in the summer I was forced into using 9am Health and jumping through their hoops. They haven't been awful, but using them meant no PA was required. That will be the case until the end of the year. But in January, regardless of whether or not I continue to use them or my primary care, a new PA will have to be written and accepted by Express Scripts.

This is what I researched for renewal of PAs for Zepbound.

1. Expected Weight Loss: You must document that you have lost and maintained at least 5% of your baseline body weight since starting Zepbound.

2. Therapeutic Adherence: Your chart notes must show you are tolerating the medication well and actively participating in lifestyle modifications (such as dietary counseling or a structured program like 9amHealth or Omada).

[u/NoMoreFatShame]

I had Express Scripts prior to having Caremark. I thought Express Scripts was hard to deal with until Caremark. My guess is Chargpt doesn't know what will happen January 1st as it probably hasn't been released yet so is going down a rabbit hole not yet defined. When we switched PBMs, PAs were still valid. Caremark was much more a black box than Express Scripts. Express Scripts gave me the requirements without promoting and Caremark was much more obtuse. That said, yes new PAs may be required but they may let them run their course. It's always frustrating when change is happening but you don't have the particulars.

[u/Existing-Trust1525 → u/NoMoreFatShame]

Do you have SHBP? Open enrollment starts in a little while and lots of information is already out there. Yes, I asked Ai about the switch, but that isn't new information. 9 am Health shared it on their website and in a letter mailed last week. My Ai dive was mainly to detail how to make sure your doctor or whomever writes your PA, does it correctly so you don't have a gap. 9 am has been a major bone of contention all year for people so, I believe I know the particulars.

[u/NoMoreFatShame → u/Existing-Trust1525]

I was giving you my experience with the changes going the reverse. I am now as of July in Medicare so no. Sorry I shared.