Here is some important information regarding your Benefits. Please read carefully:

EXPRESS SCRIPTS (Effective October 1, 2024)

GLP-1 MEDICATIONS FOR WEIGHT LOSS

FOR ACTIVES AND PRE-MEDICARE PARTICIPANTS

Effective October 1, 2024, to be able to obtain coverage for a weight loss drug or

GLP-1 medication for weight loss, at a minimum, a covered person must meet all the following requirements at the

time the drug is started:

(a) Be at least 18 years of age.

(b) Have a body mass index (BMI):

(i) Equal or greater than 32; or

(ii) Equal or greater than 27 and have at least two of the following risk factors:

(A) Type 2 diabetes

(B) Hypertension

(C) Dyslipidemia

(D) Obstructive sleep apnea

(E) Cardiovascular or coronary artery disease

(F) Knee osteoarthritis

(G) Asthma

(H) Chronic obstructive pulmonary disease

(I) Non-alcoholic fatty liver disease

(J) Polycystic ovarian syndrome

(c) Submit evidence that the covered person will or has been engaged in behavioral

modification and a reduced-calorie diet

IMPORTANT NOTE FOR THOSE

ALREADY RECEIVING COVERAGE FOR WEIGHT LOSS DRUGS: 

As of October 1, 2024, if you would not have qualified for coverage under the new criteria when you began taking the drug, you will no longer be approved for coverage. Here are two examples of how this will work:

Example 1: On June 1, 2024, Participant A had a BMI of 31 and was approved for weight loss drug coverage. As of October 1, assuming Participant A’s BMI is under 32, Participant A will not be eligible for continued coverage unless Participant A otherwise meets the new criteria.

Example 2: On June 1, 2024, Participant B had a BMI of 33 (baseline BMI) and was approved for weight loss drug coverage. As of October 1, Participant B has a BMI of 31 and, assuming all other coverage requirements are met, will be eligible for continued coverage because Participant B’s baseline BMI meets the new criteria. 

 

(a) Prior authorization is required for coverage to begin and then at least once per year in subsequent years. For each prior authorization after initial approval, have or maintain a 5% weight loss from initial weight.

(b) Enrollment and engagement with Omada, a virtual health program, provided by Express Scripts, the pharmacy benefits manager (PBM). Omada helps members create healthier habits to achieve long-lasting results. To continue coverage of a weight loss medication, you must meet the following requirements each month:

(1) Use the Omada app four times a month, by doing lessons or engaging with your health coach, peer group or online community.

(2) Weigh in four times a month using the smart scale provided by Omada. 

 

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