CommercialPrior AuthMedium impact
Pharmacy coverage changes
Harvard Pilgrim Health Care·Endocrinology, Neurology, Sleep Medicine +2 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Point32Health (Harvard Pilgrim and Tufts Health Plan) is implementing pharmacy coverage changes effective January 1, 2026. Wegovy criteria have been updated for certain indications, Zepbound coverage for sleep apnea in obesity has been removed, and Ajovy has been moved to non-formulary status requiring prior authorization.
Action Required
Before January 1, 2026: Providers must obtain prior authorization for Ajovy prescriptions for Harvard Pilgrim Commercial, Tufts Health Plan Commercial, and Tufts Health Direct patients. Update prescription workflows to check formulary status. Review updated criteria for Wegovy prescriptions on Value and Premium formularies. Stop prescribing Zepbound for moderate to severe obstructive sleep apnea in obesity as it will no longer be covered.