Weight Management

Yes. Announced during the Open Enrollment period in November 2024, changes are being made to the Plan to retain coverage of these GLP-1 weight-loss medications in 2025 for eligible individuals.

Effective January 1, 2025, there will be a 30-day supply limit for the GLP-1 medications used for weight-loss.

Beginning March 1, 2025, GLP-1 weight-loss medication coverage will be dependent on members meeting new coverage requirements.

Wegovy, Zepbound and Saxenda. These are all GLP-1 medications approved by the U.S. Food and Drug Administration (FDA) for weight management.

Express Scripts, Ohio State’s prescription drug vendor, will contact participating individuals directly with information about eligibility, enrollment, and participation.

For a medication to be covered, you must:

• Join and actively engage in the Omada online lifestyle modification program; and
• Have a body mass index (BMI) of 32 or higher before you started the medication – or a BMI of 27 or higher before you started the medication, along with two weight-related health issues.

Yes. If all the requirements are not met, the Plan will not cover any portion of the cost of GLP-1 medications for weight loss. You can pay out-of-pocket and/or use your Flexible Spending Account (FSA) funds.

No. If you take a GLP-1 for a diagnosis of diabetes, your coverage is not affected by the changes.

BMI, or body mass index, is a measure of your body composition based on your height and weight. Your provider can tell you what your BMI is, and they will work with Express Scripts to provide that information for review.

If your BMI is between 27 to 31 and you have two weight-related issues, you can qualify for coverage in EncircleRx Weight Loss.* The health issues associated with being overweight vary. Please talk to your doctor about issues you may be experiencing and whether they may meet coverage requirements.

*You will also need to enroll and actively participate in the Omada lifestyle modification program.

Omada has partnered with Express Scripts, Ohio State’s prescription drug vendor, to provide virtual programs that help provide support for health conditions. The health coaches available to you through their program are experts in weight-loss and obesity disease management, and through the program, you have access to tools and support resources to help manage weight and achieve additional health benefits. Omada can help you build healthy routines around what you like to do and where you need the most support. Working with a virtual care team, you can get assistance with reaching your goals through one-on-one health coaching and specialist support, use of smart devices, at no extra cost to you.

A letter with the enrollment instructions was mailed to your home address on December 13, 2024. Once you have received your letter, you may enroll in Omada at omadahealth.com/esi and enter the Access Code provided.

No, if you are actively participating in an Omada program, there is nothing additional you need to do. However, your active engagement in Omada is now required to maintain coverage of GLP-1s. If you currently do not have a scale, Omada will provide one when you start a weight-loss medication.

*Voluntary participation in Omada for Prevention may have previously been offered to individuals who are overweight (based on BMI), have prediabetes, or are at risk of diabetes.

Active engagement is defined as four weigh-ins and four app engagements per month. App engagements are not restrictive or specifically defined because everyone’s journey is unique and different. An engagement can be a completed lesson, a conversation with your health coach, meal tracking, adding to a peer group conversation, completing an exercise goal or many of the other activities offered by Omada. A weigh-in simply requires stepping on your scale each week and allowing it to record your weight for the day. If you previously enrolled in Omada for Prevention voluntarily, you may already be used to these activities. Your continued engagement is now a requirement to maintain coverage of GLP-1s for weight loss.

Your coach will reach out to introduce themselves, and you will receive your scale and any additional equipment necessary based on your initial enrollment responses. For the first 30 days, simply enrolling is enough to meet the engagement requirements while you wait for your equipment.

No. There are two requirements to maintain coverage of GLP-1 medications for weight loss. You must meet both requirements outlined above:

• Join and actively engage in the Omada® online lifestyle modification program; and
• Have a body mass index (BMI) of 32 or higher – or a BMI of 27 or higher, along with two weight-related health issues.

If you were already on a weight-loss medication, a letter outlining the new coverage requirements, and the actions required by you and your physician was mailed to your home address on December 13, 2024. If you have not previously done so, you will be required to enroll in Omada. Your Omada access code and enrollment directions are available on the Express Scripts portal. Please talk to your doctor about your GLP-1 prescription. Beginning February 1, 2025 your doctor can submit documentation required for review by ESI before you need to refill your prescription following the March 1, 2025 program effective date.

No. Wegovy, Zepbound and Saxenda for weight-loss are limited to a 30-day supply only.