Some employers require patients to enroll and engage with Omada Health in order to receive insurance coverage for GLP-1 medications through CVS Caremark.
This article is designed to help pharmacists and providers guide patients through the Omada enrollment and engagement process and ensure they meet requirements for continued medication coverage.
Step 1: Confirm if the Patient Needs to Enroll in Omada
If a patient is seeking GLP-1 coverage through CVS Caremark and hasn't enrolled in Omada, advise them to complete the Omada application.
- Tip: The patient may have received communication from their employer or insurer stating this requirement. If uncertain, they can contact their insurance provider using the number on the back of their ID card.
Step 2: Help the Patient Complete the Omada Application
Patients can instructions on how to complete an Omada application here:
To apply, the patient will need:
- Their CVS Caremark Member ID
- Use this guide to locate their Caremark ID
- To click “Get Started” and follow the on-screen instructions
Step 3: Explain Ongoing Engagement Requirements
To stay on track and keep GLP-1 coverage, the patient needs to complete a certain number of activities on a rolling 31 day basis. (The number of activities may vary by their employer.) This means that every day, we look at the prior 31 days to see if they have done:
- App activities: Log meals, complete lessons, or engage with other parts of the Omada app; or
- Weigh-ins: Use your Omada scale to record their weight.
Important: Only one app activity and one weigh-in per day counts toward the 31-day total.
Best Practices to Recommend to Patients to Keep Their GLP-1 Coverage
Encourage Patients to Track Their Progress
To meet their Omada requirement to maintain GLP-1 coverage, the Omada in-app engagement tracker is their source of truth.
What to do:
- Enable the in-app tracker to monitor their activities and weigh-ins.
- Use the app and weigh in consistently to stay on track.
- Engage more than the minimum when possible to build a buffer and avoid gaps in coverage.
Step 4: Ensure Requirements Are Met Before the Refill
Patients must meet Omada engagement requirements before a paid claim can be processed at the pharmacy for the GLP-1.
- Once Omada confirms the patient is compliant, the status is sent to CVS Caremark within 1 day
Encourage patients to complete their requirements a few days in advance of when they need their refill to avoid delays.
Step 5: Confirm Prior Authorization
Most employers also require a Prior Authorization (PA) for GLP-1 therapy. If the patient’s PA status is unclear:
- Have them call their insurance provider using the number on the back of their ID card. Omada does not manage the prior authorization process or decision.
Who to Contact with Additional Questions
For further questions about coverage, prior authorization, or patient eligibility:
- Patients should contact their insurance provider
- Providers and pharmacists can also reach out to CVS Caremark for benefit verification or prior authorization requirements