Update on coverage of weight loss medication

By November 1, 2025 (60 days before effective date): 1) Billing team must audit all active patients on weight loss medications (GLP-1 drugs, Contrave, phentermine, etc.) and identify those covered under Core MA, Core NH, Core ME, Core RI, ConnectorCare, Select, or Tufts Health Direct formularies. 2) Front desk/clinical staff must notify affected patients by letter that coverage will terminate January 1, 2026 or upon group anniversary date. 3) Billing system must be configured to: deny claims for weight loss medication coverage on all Core/Select/ConnectorCare/Tufts formularies effective 1/1/26; automatically terminate all existing prior authorizations for weight loss medications on the effective date with no exceptions; require prior authorization for any new weight loss GLP-1 medication requests on Value or Premium formularies; flag newly prescribed GLP-1 medications to trigger behavior modification program enrollment verification before claim approval. 4) Providers must be instructed to counsel patients on alternative coverage options (prescription discount cards, manufacturer copay assistance) and document medical necessity if patients are on Premium formulary with weight loss indication. 5) Update authorization system to require 6-month behavior modification program completion documentation before approving new GLP-1 weight loss claims on fully insured plans with coverage. Failure to implement these controls will result in claim denials and compliance violations.