Anthem Blue Cross Blue Shield Rybelsus coverage appeal

Anthem Blue Cross Blue Shield prior authorization criteria for Rybelsus

• •BMI ≥30 (or ≥27 + comorbidity)
• •Step therapy: trial of phentermine or orlistat unless contraindicated
• •Documented lifestyle program participation

Step-by-step appeal flow

1. 1

   Pull your carrier policy bulletin

   Anthem Blue Cross Blue Shield publishes its Rybelsus coverage criteria. Read it first — every successful appeal cites it back to the reviewer.

2. 2

   Document your medical necessity

   BMI ≥30 (or ≥27 + comorbidity) Step therapy: trial of phentermine or orlistat unless contraindicated Documented lifestyle program participation

3. 3

   Have your prescriber submit the PA

   Most Anthem Blue Cross Blue Shield PAs go through CoverMyMeds or the carrier portal. Your prescriber attaches BMI history, comorbidities (with ICD-10 codes), lifestyle program participation, and prior weight-loss attempts.

4. 4

   If denied — file the appeal within 60 days

   Reference Anthem Medical Policy 56820. Document step-therapy failures with specific drug names + dates.

5. 5

   Submit external review if internal appeals fail

   After two internal appeals, you can request external review through your state insurance commissioner. ERISA plans go through the federal external-review process.