This article details the Formulary Customizations update within the COM (Clinical Obesity Management) product. This change allows Vida to reflect specific prescription benefit manager (PBM) or health plan formulary restrictions directly within the member's experience.
Table of Contents
Key Workflow Changes & Member Options
What is this Update?
This update allows Vida to manage and communicate formulary changes affecting the member's weight-loss medication coverage.
- This system helps when the plan removes payment for weight-loss medicine due to formulary changes.
- Members can still enroll in the Medical Weight Loss and Advanced Medical Service (prescribing) programs. This update only affects the medication coverage.
- Lower-cost options will still be prioritized when available.
Key Workflow Changes & Member Options
This workflow gives us clear ways to help and tell members when their medicine is not covered by their plan.
1. Medication Options When Not Covered
| Medication Type | Formulary Status | Member Option | Priority |
|---|---|---|---|
| AOMs | None covered by formulary | Member will have the option to self-pay. | Lower-cost AOMs are prioritized when covered. |
| GLP-1s | None covered by formulary | Member will have the option to self-pay. |
Self-Pay GLP-1 for Lilly Direct
Lilly Self-Pay Pharmacy Direct Solutions refers to a direct-to-consumer pharmacy option offered through LillyDirect (Eli Lilly’s digital healthcare platform) that allows members to “self-pay” for Zepbound without using health insurance.
📍 Key Lilly Medications that Vida Prescribes
- Zepbound
✅ Providers must send the prescription to:
- Pharmacy Name: LillyDirect Self Pay Pharmacy Solutions
-
NPI: 1689411712
- CPDP Pharmacy ID: A unique national ID for pharmacies, crucial for payer transactions.
- NCPDP: 3692539
- Address: 4343 Equity Dr, Columbus, OH 43228
☎️ Customer service phone number: 800-545-5979
⚙️ How it Works
Members will receive a text message or email from LillyDirect to confirm their prescription and finalize details.
- Explain that they will need to complete their order online and pay for their prescription
- In most cases, the medication will be shipped the next business day.
🔑 Key Points
- If a member asks about Lilly Cares, advise them that it does not cover Mounjaro or Zepbound.
- A member CANNOT use Lilly Cares as this to the provider.
Self Pay GLP-1 Option for Novo Nordisk
NovoCare® Pharmacy is a direct-to-patient pharmacy service supported by Novo Nordisk that allows members to “self-pay” for Wegovy without using health insurance.
📍 Key Novo Nordisk Medications that Vida Prescribes
- Wegovy
✅ Providers must send the prescription to:
- Pharmacy Name: NovoCare® Pharmacy
- NPI: 1710671854
-
NCPDP: 5758074
- NCPDP Pharmacy ID: A unique national ID for pharmacies, crucial for payer transactions.
- Address: 2400 Sand Lake Rd, Ste. 200B, Orlando, FL 32809
☎️ Customer service phone number: 888‑809‑3942
⚙️ How it Works:
- Members will receive setup instructions. After setup is complete, they can pay for their prescription and schedule their delivery.
- The member will receive reminders by text message or phone call when it’s time for a refill.
-
CoAssist Pharmacy is a dispensing pharmacy for NovoCare® Pharmacy.
- CoAssist Pharmacy phone number: 855-382-2533
🔑 Key Points
Novo Nordisk has a Patient Assistance Program (PAP) - It does not cover Wegovy, but does cover Ozempic.
- If the member takes Ozempic, let them know we CANNOT assist with this program because the medication is sent directly to the Provider's office to be given to them.
2. Client Configuration
This feature is set up in B2B when we start with a new client. If that client decides they will not pay for the weight-loss medicines, B2B shows a notice banner (for example, the "COM Formulary Customization Banner").
3. Clients Using This Configuration
As of November 2025, the following clients are utilizing this configuration:
The Banner System (Visual Guide)
The same banner message now appears in the Health Guide Platform and for the Care Team (coaches/providers). This ensures Agents and the Care Team share the same, correct information about the member's medication coverage.
Banner Appearance and Placement
- Color: The banner appears in purple.
- Visibility: The banner is visible to the member's care team (coach, RD, therapist, Care navigator, Care coordinator, Clinical assistant, and medical providers) and Member Services Agents.
Health Guide Dashboard Banner
This banner makes ensures Member Services Agents and the Care Team have the same message.
Banner Text: GLP-1s not covered by formulary; member may elect self-pay.
Provider Dashboard Banner
The banner ensures a consistent message across the entire team.
Banner Text: GLP-1s not covered by formulary; member may elect self-pay.
Answering Member Questions
This section provides clear, approved responses for common member questions regarding treatment planning, medication choice, and safety.
| Member Question | Agent Talking Point (Verbal) | Written Response (For Macro/Email) |
|---|---|---|
| "What's Vida's main goal for people like me?" | Our goal is to help you reach better health like losing weight safely and improving your blood pressure, cholesterol, or blood sugar. | Vida's goal is to help you get healthier—lose weight safely and improve things like blood sugar and blood pressure. |
| "How do I know Vida's care is safe?" | Your safety always comes first. Every medication and care plan we use is chosen with that in mind. | Your safety is our top priority in every care plan. |
| "Do you prescribe compounded or imitation GLP-1s?" | No, we only prescribe approved medications—generic or name brand. We don’t use compounded or imitation GLP-1s because your safety comes first. | We only prescribe safe, approved medications—not compounded or imitation GLP-1s. |
| "Why not start with the newest or most popular medication?" | Starting with a lower-cost medication that works for your body helps you save money and keep treatment going even if your insurance changes. | We may start with safe, lower-cost medication that works for you and fits your budget long term. |
| "Why do I need to stay on the same medicine for a few months before switching?" | Your body needs time to adjust so you get the full benefit. We usually give a medication several weeks—and sometimes up to 12 weeks—before changing or adding another. | We give each medication time to work while you’re also making eating and exercise changes. We usually monitor for several weeks and up to 12 weeks before changing or adding another medication. |
| "How does my provider decide what treatment is right for me?" | Your provider looks at your past weight loss, other health conditions, lab results, and medications you’re using. They talk with you to make a plan that fits your body, health risks, living situation, and budget. | Your plan is based on your health history, goals, and what your body and budget can handle. |
| "Why can’t I get a certain medicine right away?" | Sometimes your health plan has stricter rules than general medical guidelines, especially for GLP-1 medicines. Vida follows both our science-backed clinical approach and your plan’s rules. | We follow your health plan’s formulary or medication list coverage rules when prescribing, especially for GLP-1 medicines. |
| "What happens if my plan stops paying for my medicine?" | If that happens, we’ll review your options together. You can stay in the program for support. Options include lower-cost medicines, behavior-only care, or paying for certain medicines yourself. | If your plan stops covering a medication we’ll help you choose what’s next—like a lower-cost drug, continued behavior change care, or self-pay options. |
| "Is a small amount of weight loss really worth it?" | Yes! Losing just 5% of your weight can lower future health risks and help you feel better day to day. | Even a 5% weight loss can improve health and lower your risk for future problems. |
Key Clinical Rationale (For Agent Context)
This section provides the underlying justification for the clinical answers above.
- Clinical Goal: Vida's goal is to deliver better health outcomes, which includes significant weight loss and improvement in related conditions like blood pressure and blood sugar.
- The 5% Difference: Losing at least 5% of starting weight significantly reduces the risk of future health problems and improves mood and quality of life.
- Treatment Rationale: Providers prioritize lower-cost medicines first to maximize insurance benefits and ensure the member can afford long-term treatment. Providers also strive to reach the maximum tolerated dose before switching or adding expensive medicines.
- Safety & Prescribing: Vida follows all federal and state laws and does not prescribe compounded or unregulated GLP-1 imitations. All prescribing is done according to Vida’s evidence-based guidelines and must adhere to the member's specific health plan formulary.
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