CommercialPrior AuthMedium impact
Pharmacy coverage changes and 2026 formulary updates
Harvard Pilgrim Health Care·Endocrinology, Pulmonology, Family Medicine +2 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Point32Health (Harvard Pilgrim and Tufts Health Plans) is updating pharmacy coverage for 2026, including removing Pulmicort Flexhaler from step therapy for asthma medications and adding stricter requirements for weight loss medications like Zepbound. The changes also clarify coverage restrictions for Wegovy based on formulary type and exclude certain conditions.
Action Required
By January 1, 2026: Billing and clinical teams must update prior authorization processes for Asmanex and Fluticasone propionate (no longer require Pulmicort Flexhaler trial first). For Zepbound prescriptions, verify patients have completed required 6-month behavior modification program before prescribing. Update Wegovy prior authorization requests to exclude type 1 diabetes patients for cardiovascular prevention coverage and note that sleep apnea coverage for Zepbound has been removed.