Nyack, Burke, and St. Luke’s GLP1 Requirements FAQ

Description | Used for: Use this article to address member concerns and questions from Nyack, Burke, and St Luke’s. These members were previously participating in Lark (similar digital health program) prior to joining Omada.

Pharmacy benefit manager (PBM): 

Carelon

Requirements

Important: This timing is for internal reference only and should not be proactively communicated to members. 

Engagement Requirements

Grace Period

• There is a 1 month grace period for newly enrolled members.

Engagement Lookback 

• Rolling 30 days

Engagement Requirements 

• Members must complete engagement requirements within a rolling 30 day basis to remain eligible for GLP-1 coverage through Omada.
  • Note: Engagement is measured by reviewing activity from the past 30 days on a rolling basis.
• On a rolling 30 day basis, the member needs:
  • 4 weigh-ins
  • 4 engagement activities
• A member can complete ONE weigh-in and ONE engagement activity on the same day.
• Any additional weigh-ins or engagement activities completed on the same day will not count toward their engagement progress.
  • Engagement activity includes actions such as setting or updating goals, tracking activity, completing lessons, logging food, and sending messages to your coach.

FAQ

1. What happens if a member’s account is closed or expired?
   1. They will need to re-apply. Use the chart above to find the specific landing page.
2. How is an application processed?
   1. Following the normal direct application process for Omada. 
      1. Re-enrolls are allowed for members.
3. How can I see if an applicant has met the Enrollment requirement?
   1. Check the member's Orange page to find the "Account Created At" date. 
      1. Applicants are sent to Carelon on the Application Report.
4. How can I see if a member has met the Engagement requirement? 
   1. Member Services does not have visibility into a member’s engagement progress for this deployment. 
   2. If a member reports completing the engagement requirements:
      1. Confirm the approximate date they believe completion occurred. 
      2. If more than 1 business day has passed since that date, escalate the member’s information to CSM Megan Saylor following the process outlined in Step 11. 
      3. Megan will escalate the request to Carelon for review.
   3. If a member is unsure of their engagement progress status and is seeking clarity:
      1. Escalate the member’s information to Taylor Douglas following the process outlined in Step 12.
      2. Taylor will confirm their current engagement progress.
5. How do we notify Carelon the applicant met their Enrollment and/or their Engagement requirement? 
   1. Omada will send Carelon the Application and Engagement Report daily. 
   2. Once Omada sends the requirement status to Carelon, it takes 1 business day for this to be reflected in Carelon’s system/PA override. 
6. How often is data sent to Carelon?
   1. Daily
7. When will the new data be reflected within Carelon’s system?
   1. 1 business day after the file is sent from Omada.
8. Who can answer questions about medication coverage?
   1. WPH has a dedicated Rx Member Services Line: 855-350-1267
9. What if the applicant does not meet CEC requirements and can't enroll?
   1. As long as Members are listed as rejected on the Application Report and Carelon completes a PA override, if appropriate. 
      1. Reminder: Once the report sends from Omada, it takes 1 business day for this to be reflected in Carelon’s system.
10. What should I do if I have an escalated member?
    1. Offer to initiate a 3-way call with Rx Member Services Line: 855-350-1267, the member, and Omada.If the member agrees, 3- way call following this IKB.
    2. If the member does not want to move forward with a 3-way call, kindly suggest that they call Rx Member Services Line: 855-350-1267.
11. What should I do if I have specific deployment questions?
    1. Reach out to CSM, Megan Saylor, in #help-support for questions about the overall process. DO NOT discuss member specific issue details via the #help-support channel. Inform Megan S. that you will be sending a request via Virtru email regarding a member's request.
    2. Reminder: No PHI, including member ID or information about the person, is authorized to be in that slack channel and no one in the commercial org outside or the Client Services group is authorized to troubleshoot issues about individuals. 
    3. If you need to share member specific information, email Megan with Virtru on and include the following:
       1. Member full name 
       2. DOB
       3. Anthem member ID
       4. Enrollment status
       5. Employer/hospital: Nyack, Burke, or St. Luke’s
       6. Issue summary
       7. Confirmation it has been past 1 business day since Omada notified Carelon 
12. What should I do if a member asks for an update on their engagement progress? 
    1. Send request via Virtru email to Product Manager, Taylor Douglas, regarding a member requesting engagement progress details.
    2. Please do not post a heads-up for Taylor in the #help-support channel. MNav will soon be able to review engagement reports directly in the Tableau dashboard. More details to come!
    3. Reminder: No PHI, including member ID or information about the person, is authorized to be in that slack channel and no one in the commercial org outside or the Client Services group is authorized to troubleshoot issues about individuals. 
    4. If you need to share member specific information, email Taylor with Virtru on and include the following:
       1. Member full name 
       2. DOB
       3. Anthem member ID
       4. Enrollment status
       5. Employer/hospital: Nyack, Burke, or St. Luke’s
       6. Issue summary
13. When do these members need to get their PA?
    1. After their Omada requirement is met.
    2. Members should be directed to Carelon for PA questions.
    3. You may provide the member with Requests for Authorizations/Retro-authorizations link.
14. Macro explaining requirements: GLP1:: Nyack, Burke, or St Luke’s GLP-1 Requirements Inquiry.