CommercialPrior AuthHigh impact
Update on diabetic GLP-1 and GIP/GLP-1 drug coverage
Harvard Pilgrim Health Care·MA · Endocrinology, Family Medicine, Internal Medicine +1 more·Pharmacy
Effective date
May 1, 2026
We identified it
Jun 20, 2026
Summary
Harvard Pilgrim Health Care and Tufts Health Direct are removing automated step therapy for diabetic GLP-1 and GIP/GLP-1 medications (Ozempic, Mounjaro, Trulicity, etc.) effective May 1, 2026. All patients will now require prior authorization regardless of previous oral diabetes medication use, with coverage limited to type 2 diabetes patients who have tried or are currently taking oral hypoglycemic agents.
Action Required
Before May 1, 2026: Billing team and providers must update workflows to require prior authorization for ALL diabetic GLP-1 and GIP/GLP-1 medications (Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity) for Harvard Pilgrim and Tufts Health Direct members. Update EMR templates to document type 2 diabetes diagnosis and oral hypoglycemic agent trial/failure. Train staff to submit requests through medical review process per Pharmacy Medical Necessity Guidelines for Incretin Mimetics. Claims will be denied without proper prior authorization.