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Harvard Pilgrim Health CareCommercial · Coverage · Pharmacy · MA, NH, ME, RI · Endocrinology, Family Medicine, Internal Medicine +2 moreHigh impact

Update on coverage of weight loss medication

Effective date
Jan 1, 2026
Identified
Jun 20, 2026

Summary

Harvard Pilgrim Health Care and Tufts Health Direct will exclude coverage of weight loss medications including GLP-1 drugs for weight loss and alternative indications (cardiovascular conditions) starting January 1, 2026. Plans that retain coverage will require a 6-month behavior modification program for new GLP-1 prescriptions, with Zepbound as the preferred medication.

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What to do

Action · 3 steps
01Before January 1, 2026: Billing team must identify all Harvard Pilgrim and Tufts Health Direct patients currently on weight loss medications and verify their formulary type (Core, Select, ConnectorCare = no coverage; Value, Premium = coverage remains).
02Update prior authorization workflows to include 6-month behavior modification program requirement for new GLP-1 weight loss prescriptions.
03Train staff to check formulary before prescribing weight loss medications as existing authorizations will be terminated without grandfathering.

Original notice

Update on coverage of weight loss medication
point32health.org · Always check the source before changing claims.
View original ↗

Related changes

See all Harvard Pilgrim Health Care changes →
Update on coverage of weight loss medicationHighEffective Jan 1, 2026 · PharmacyReminder: weight loss medication coverage updateHighEffective Jan 1, 2026 · PharmacyReminder: weight loss medication coverage updateHighEffective Jan 1, 2026 · PharmacyBrowse every Harvard Pilgrim Health Care change in the policy list

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Harvard Pilgrim Health Care policiesMA policy changesNH policy changesME policy changesRI policy changesEndocrinologyFamily MedicineInternal MedicineGeneral PracticeCardiology

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