Does Blue Cross Blue Shield cover metformin?

In this article:

• Does Blue Cross Blue Shield cover metformin?
• Metformin cost
• Cost with BCBS
• How to check your coverage
• Which weight loss drugs are covered?
• Is Blue Cross good for managing diabetes?
• How to save

In this article

• Does Blue Cross Blue Shield cover metformin?
• Metformin cost
• Cost with BCBS
• How to check your coverage
• Which weight loss drugs are covered?
• Is Blue Cross good for managing diabetes?
• How to save

If you have Type 2 diabetes—or you know someone who does—chances are you’ve heard of metformin. It’s a popular prescription drug, and over 150 million people take it worldwide each year. Metformin is FDA-approved for people over 10 years of age who have Type 2 diabetes, and is a relatively affordable option for managing blood sugar. However, cutting out-of-pocket costs is always attractive, so you might wonder if your Blue Cross Blue Shield plan will cover it. Insurance plans often cover metformin, but there are some important factors to keep in mind. 

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Does Blue Cross Blue Shield cover metformin?

For most people, Blue Cross Blue Shield health insurance will cover metformin. But ultimately, it depends on your specific plan. Blue Cross Blue Shield isn’t one single company—rather, it’s a collection of 33 locally operated companies, each with its own plans and policies, so your coverage could be completely different from someone living in the next state. Even though many people who have Type 2 diabetes receive coverage, there are still a few variables to consider.

Medical condition

Insurance companies are more likely to cover drugs prescribed for FDA-approved uses—in this case, specifically for the treatment of Type 2 diabetes. However, “even though many prescriptions for metformin are technically off-label—for things like prediabetes, PCOS, or weight management—we still see good coverage because metformin is inexpensive,” says Dr. Rekha Kumar, MD, Obesity Medicine Specialist at Found. “The one place I see more scrutiny is with extended-release versions, which sometimes require extra steps for approval.”

Prior authorization

Per Dr. Kumar, “Metformin is usually straightforward—prior authorization isn’t common because it’s generic and low-cost. The exceptions are when it’s prescribed for something outside of type 2 diabetes, like PCOS, or if a specific formulation is requested, such as extended-release.”

Some plans might also require prior authorization before they approve coverage. This is essentially asking for proof that metformin is medically necessary. Sometimes, it’s as simple as the prescriber sending documentation of certain symptoms, but other times it might require step therapy—trying a diet plan, exercise regimen, or other drugs for a certain amount of time before progressing to metformin.

Formulary classification

Every insurance plan has a drug list that shows how it classifies various covered medications. This is called a formulary, and it typically ranks drugs into categories such as generic, preferred brands, non-preferred brands, and specialty drugs. Generics often receive the best coverage, and since metformin is a generic drug, it typically falls into this tier.

How much does metformin cost?

Even without insurance coverage, metformin is still more affordable than some antidiabetic drugs. People paying completely out of pocket often pay around $165 for 60, 500 mg tablets—a 30-day supply. That’s nearly $2000 over an entire year, although there are plenty of ways to reduce that cost, whether you have insurance or not.

How much does metformin cost with Blue Cross Blue Shield?

If BCBS covers metformin, you might still be responsible for copays until you meet your deductible. However, the copay amount will vary based on the plan. Some plans cover the entire amount, leaving a $0 copay, while others might cover a large percentage, leaving a small amount leftover for you to pay. Either way, if you have coverage, you likely won’t end up paying an exorbitant amount for metformin. 

How to check whether your Blue Cross Blue Shield plan covers metformin 

There are a few different ways to check your plan’s metformin coverage:

• The formulary: Many BCBS companies have links to each plan’s formulary on their website. For example, Michigan’s Blue Cross Blue Shield website houses its drug lists under the “Resources” tab. You can also request a printed copy by calling the member services number. On the formulary, locate metformin and note its tier. This will inform you of the coverage details.
• Member portal: Each member has a portal that they can access through their BCBS company’s website. Once logged in, users can view their benefits and a list of covered drugs, including the formulary. Some companies even have a search function that provides price estimates at local pharmacies.
• Member services: The back of your insurance card has a member services phone number. Call this number to discuss your prescription drug coverage with a support representative.

What weight loss medications are covered?

Metformin is sometimes prescribed off-label for weight loss; however, since it’s not an officially approved use, BCBS or Medicare plans may not cover it for this purpose. According to Dr. Kumar, “many insurance plans still don’t cover anti-obesity medications, despite the evidence that they improve long-term health outcomes and lower costs related to diabetes and heart disease.” Some plans may include coverage for other weight loss medications, while others may not.

Plans are more likely to cover generic options, such as metformin, than more expensive brand-name drugs, like Wegovy, Ozempic, or Saxenda. Either way, members typically need to have one of the following conditions:

• A body mass index (BMI) of 30 or higher
• A BMI of 27 or higher, plus a weight-related health condition like Type 2 diabetes, heart disease, or high blood pressure.

Like with metformin, these plans might require prior authorization before covering weight loss drugs. Specifically, they might require documentation of a diet and exercise plan, or they might dictate that a patient needs to try that plan for a certain number of months beforehand.

Is Blue Cross good for managing diabetes?

Blue Cross Blue Shield offers certain plans that include specific diabetes management programs. Not every plan or BCBS independent licensee offers them, but when they do, these benefits might include:

• Free glucose meter
• Unlimited free test strips and lancets
• Discounted or $0 cost diabetes drugs (sometimes metformin)
• Free diabetes-related labs or screenings
• Specialized support

Not every plan will include all of these benefits, but even a couple can be incredibly helpful for staying on top of your diabetes treatment.

For individuals who require brand-name or specialty diabetes medications in addition to metformin, some plans also offer coverage for these options. The coverage isn’t typically as comprehensive as it is for generic drugs, but it still makes these drugs more accessible. The only surefire way to know if your plan covers specific prescription medications is by checking the formulary.

How to save on metformin

Whether or not you receive assistance from your insurance company, there are ways to reduce the out-of-pocket costs of metformin. Here are a few of the most reliable:

• Free metformin coupons: SingleCare coupons can reduce the cost of metformin to as low as $5—no insurance required. Sign up for free, then present the coupon card at any participating pharmacy to reap the rewards.
• 90-day prescriptions: Studies have shown that getting a 90-day prescription instead of a 30-day one can save money, so it’s worth asking your healthcare provider to write one.
• Medicaid: Funded by both state and federal governments, Medicaid is designed to help individuals who need assistance with medical expenses, including prescription drugs. You can get Medicaid even if you have private health insurance—you just need to meet your state’s income and eligibility requirements.
• Compare prices: Drugs can be priced differently at different pharmacies, even in the same vicinity. Checking the metformin price at several different pharmacies may save you money.

Your healthcare provider can be another valuable resource when you’re looking for savings. They can provide personalized recommendations tailored to your specific condition, financial situation, insurance plan, and preferences.