CommercialPrior AuthMedium impact
Pharmacy coverage changes
Harvard Pilgrim Health Care·Pharmacy, Endocrinology, Internal Medicine +1 more·Pharmacy
Effective date
Nov 15, 2026
We identified it
Sep 2, 2026
Summary
Empagliflozin-containing SGLT2 inhibitors are transitioning to non-formulary status with a new prior authorization requirement for Harvard Pilgrim Commercial and Tufts Health Plan Commercial effective November 15, 2026. Billing teams must implement prior authorization verification and documentation requirements before this date to prevent claim denials.
Action Required
By November 15, 2026: Billing team must update pharmacy billing system to require prior authorization for all empagliflozin-containing SGLT2 inhibitor prescriptions for Harvard Pilgrim Commercial and Tufts Health Plan Commercial members. Coordinate with prescribers and pharmacy staff to implement PA workflow in EMR/pharmacy management system. Update patient eligibility verification process to flag empagliflozin prescriptions for PA requirement. Ensure claims cannot be submitted without documented prior authorization approval. After effective date, claims submitted without prior authorization for these plans will be denied.