MedicaidCoverageHigh impact
Coverage of GLP-1s for Tufts Health RITogether members
Harvard Pilgrim Health Care·RI · Cardiology, Endocrinology, Gastroenterology +5 more·Provider Newsletter
Effective date
Oct 1, 2026
We identified it
Sep 3, 2026
Summary
Effective October 1, 2026, Tufts Health RITogether (Rhode Island Medicaid) will no longer cover GLP-1 medications when prescribed solely for weight loss, including Saxenda, Wegovy, Zepbound, and Foundayo. However, Wegovy and Zepbound remain covered for specific FDA-approved indications (cardiovascular risk reduction, MASH with advanced fibrosis, and moderate-to-severe sleep apnea). GLP-1s approved for type 2 diabetes treatment will continue to be covered. All existing prior authorizations for weight-loss use will be end-dated by September 30, 2026, and affected members will be notified.
Action Required
By September 30, 2026: (1) Billing and clinical teams must audit all active Tufts Health RITogether prior authorizations for GLP-1 medications to identify which are for weight-loss indication only. (2) For weight-loss-only authorizations, proactively notify members and providers that coverage will end on September 30, 2026, and no claims will be reimbursed after that date for this indication. (3) For Wegovy and Zepbound, verify the medical indication on each authorization; if not documented for cardiovascular risk reduction (Wegovy), MASH with F2-F3 fibrosis (Wegovy), or sleep apnea (Zepbound), end-date the authorization. (4) For type 2 diabetes GLP-1 medications (Ozempic, Mounjaro, Trulicity, generic Victoza, Rybelsus, Exenatide), no action is required for existing authorizations—they remain in force. (5) Update billing system rules and prior authorization templates to reflect that weight-loss indications are non-covered effective October 1, 2026. (6) Implement workflow to flag any new prior authorization requests for GLP-1s submitted on or after October 1 for review against the updated 'Pharmacy Products Without Specific Criteria' MNG (to be posted October 1). (7) For members under 21, ensure requests are reviewed for EPSDT compliance. Failure to process these changes will result in claim denials and member confusion.