CommercialCoverageMedium impact
Pharmacy coverage changes
Harvard Pilgrim Health Care·Endocrinology, Family Medicine, Internal Medicine +1 more·Pharmacy
Effective date
Apr 1, 2026
We identified it
Jun 20, 2026
Summary
Harvard Pilgrim and Tufts Health Plan Commercial plans will exclude new-to-market pharmacy drugs from coverage starting June 1, 2026, with exceptions only for life-threatening conditions. Additionally, Tresiba (insulin) will move to non-formulary status on Select and Value formularies effective April 1, 2026.
Action Required
By March 15, 2026: Billing team must identify patients on Tresiba insulin and initiate prior authorization requests or medication changes for Harvard Pilgrim and Tufts Commercial Select/Value formularies. By May 15, 2026: Update billing procedures to require prior authorization for all new-to-market drugs, with expedited processing for life-threatening conditions per Non-Formulary Exceptions Guidelines.