GLP-1 Use Case Overview

Description: This article defines the three operational models (Use Cases) for Vida’s GLP-1 prescribing and Prior Authorization services. It explains how insurance coverage functions for the member in each scenario.

Quick Reference: GLP-1 Use Cases

⚠️ CRITICAL: Check Pay Org Specifics

Always refer to the specific Paying Org Knowledge Base article or VP Card.

• Use Case 1 often has specific engagement requirements (e.g., app usage, coaching sessions) that the member must meet before the PA file is sent.

• Coverage Rules can  vary significantly by organization.

Use Case 1: GLP-1 Companion for Prior Authorization (PA)

Definition: Organizations under this model require members to enroll and participate in Vida to obtain coverage for GLP-1s that are prescribed by a doctor outside of Vida (e.g., their PCP or specialist).

• Role of Vida:Vida functions as the Prior Authorization (PA) facilitator. We transmit the PA file to the Pharmacy Benefit Manager (PBM) to certify member enrollment and the fulfillment of required engagements, thereby authorizing the pharmacy to process the claim.

• Member Experience:

  • The member sees their own doctor for the prescription.

  • They enroll in Vida to "unlock" coverage.

  • Once requirements are met, they see a "Coverage Unlocked" message in the app.

• Key Constraint: Members often must complete specific engagement milestones (e.g., 4 weeks of coaching, food logging) before the PA is submitted. Check the paying org specific KB article, VP Card, or prescribing overview for these details.

Use Case 2: Preferred Prescriber

Definition: Organizations under this model offer Vida as a voluntary option for receiving GLP-1s.

• Role of Vida: Vida is a full-service provider (Medical Weight Loss program) that can prescribe medication if preferred by the member.

   

• Member Experience:

  • Flexibility: The member can choose to get their GLP-1s from a Vida provider OR their local doctor.

  • Coverage: Insurance covers the medication in either scenario (assuming the member meets clinical eligibility).

• Workflow: If the member chooses Vida, they enroll in the MWL program and opt-in to the prescribing service.

Use Case 3: Sole Prescriber

Definition: Organizations under this model have a "narrow network" for GLP-1s, meaning they only cover these medications if they are prescribed by Vida.

• Role of Vida: Vida is the exclusive path to coverage.

• Member Experience:

  • If a member gets a prescription from their local doctor, insurance will deny it.

  • The member must enroll in Vida and see a Vida Medical Provider to get the medication covered.

• Workflow: Similar to Use Case 2, but the "choice" is removed if they want insurance to pay for the drug.

Use Case 1 & 2: Engagement Requirement & Preferred Prescriber

Definition: Organizations under this hybrid model provide the most flexibility but with strict rules. Members can receive GLP-1 coverage for prescriptions from an outside doctor (contingent on Vida participation) OR they can choose to have Vida prescribe the medication directly.

Role of Vida: Dual Role.

• For Outside Doctors: Vida acts as the PA Facilitator (Gatekeeper). We monitor engagement to approve the PA.

• For Vida Doctors: Vida acts as the Prescriber. We write the script and manage the care.

Member Experience:

• The "Choose Your Path" Model: The member must decide if they want to keep their own doctor or switch to a Vida provider.

• Path A (Outside Doctor): The member keeps their local doctor. To get the drug covered, they must enroll in Vida and meet engagement milestones (e.g., food logging, coaching calls) to "unlock" the PA.

• Path B (Vida Provider): The member enrolls in Vida’s Medical Weight Loss program and receives the prescription directly from a Vida clinician (if eligible).

Key Constraint:

• Confusion Risk: Agents must determine if the member is trying to keep their doctor (Path A) or switch to Vida (Path B), as the steps for members  can differ significantly.

• Engagement is Mandatory: Regardless of which path they choose, the member is required to actively participate in the Vida program to maintain coverage.