CommercialCoverageHigh impact
Reminder: weight loss medication coverage update
Harvard Pilgrim Health Care·MA, NH, ME, RI · Endocrinology, Family Medicine, Internal Medicine +2 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Harvard Pilgrim and Tufts Health Direct are significantly restricting weight loss medication coverage effective January 1, 2026. Most formularies will exclude all weight loss drugs including GLP-1 medications, with new prior authorization requirements and a mandatory 6-month behavior modification program for remaining covered plans.
Action Required
Before January 1, 2026: Billing team must update prior authorization workflows for weight loss medications on Harvard Pilgrim and Tufts Health Direct plans. Verify patient formulary type (Core, Select, ConnectorCare exclude coverage; Value and Premium may maintain coverage). For patients with existing approvals, notify that authorizations will terminate January 1, 2026 with no grandfathering. Update systems to require ResetStrong behavior modification program completion for new GLP-1 weight loss prescriptions on covered formularies. Claims will be denied without proper authorization after effective date.