Massachusetts Medicaid: Coverage change for weight loss and obesity drugs

By July 3, 2026: (1) Billing team must update claim submission workflows to deny or flag claims for the following drugs when billed with weight loss/obesity diagnosis codes (E66.x series): Contrave, Didrex, Dietylpropion, Lomaira, Adipex-P, Mounjaro, Ozempic, Phendimetrazine, Qsymia, Saxenda, Wegovy, Xenical, and Zepbound. (2) Providers must submit prior authorization through the UnitedHealthcare Provider Portal for ANY of these drugs when prescribed for Medicare-covered indications (e.g., type 2 diabetes, cardiovascular disease) to ensure payment. (3) Update encounter forms and clinical documentation templates to require providers to specify the diagnosis justification (not weight loss/obesity) when prescribing these medications. (4) Brief front-desk and billing staff: claims will be DENIED without proper prior authorization for non-weight-loss indications. (5) Review current patient accounts with active prescriptions for these drugs; contact patients and providers now to update authorizations for legitimate covered indications before the effective date.