Jun 04, 2025
Pharmacy updates for 2026
Based on market demand, Blue Shield is introducing a lower premium prescription rider for Enhanced Rx $15/20%/30%/40%. This plan is available for either the Plus or Value formulary and customization is allowed following the standard.
- Tier 1 will include a $15 copayment to encourage the utilization of generic drugs
- Tier 2 will apply 20% coinsurance, up to $250 maximum per prescription
- Tier 3 will apply a 30% coinsurance, up to $250 maximum per prescription
- Tier 4 will apply a 40% coinsurance, up to $250 maximum per prescription
Updated weight loss drug exclusion and pharmacy riders
Effective 1/1/2026, Blue Shield will apply a benefit exclusion for weight loss drugs upon group renewal. This exclusion was implemented for IFP and small group customers on 1/1/2025 and aligns with policies of other carriers in the California market.
With the weight loss exclusion, drugs for weight loss will only be covered for members with Class 3 obesity, which is defined as having a BMI of 40 or greater. Prior authorization will be required, and members are required to enroll in a comprehensive weight management program such as Wellvolution prior to and while taking the drug. Groups eligible for customization may opt-out with an additional premium impact.
Weight loss pharmacy riders
Blue shield is introducing a portfolio option for groups who wish to offer weight loss drug coverage (BMI≥30, or BMI≥27 with certain conditions). These plans are available with the Plus formulary customization of cost shares is. The plans are:
- Enhanced+ Rx $10/25/40 with $0, $150, or $250 Pharmacy Deductible
- Enhanced+ Rx $10/30/50 with $0, $150, or $250 Pharmacy Deductible
- Enhanced+ Rx $15/30/45 with $0, $150, or $250 Pharmacy Deductible
For more 2026 updates see Blue Shield Large Group Expands Medical Plans for 2026
