CommercialCoverageHigh impact
Reminder: weight loss medication coverage update
Harvard Pilgrim Health Care·MA, NH, ME, RI · Endocrinology, Family Medicine, Internal Medicine +2 more·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Harvard Pilgrim and Tufts Health Direct will significantly restrict weight loss medication coverage starting January 1, 2026. Most formularies will exclude all weight loss drugs including GLP-1s, while remaining coverage will require a 6-month behavior modification program for new patients. Existing authorizations will be terminated without grandfathering.
Action Required
By January 1, 2026: Billing team must update prior authorization requirements for weight loss medications. Verify patient formulary (Core, Select, ConnectorCare, and Tufts Health Direct exclude all coverage; Value and Premium may maintain coverage with new ResetStrong program requirement). Update encounter forms to alert providers that existing weight loss medication authorizations will be terminated without grandfathering. For new GLP-1 prescriptions on covered formularies, patients must complete 6-month behavior modification program before coverage approval.