CommercialCoverageHigh impact
Update on coverage of weight loss medication
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 Health Care and Tufts Health Direct will exclude coverage of weight loss medications including GLP-1 drugs for weight loss and alternative indications (cardiovascular conditions) starting January 1, 2026. Plans that retain coverage will require a 6-month behavior modification program for new GLP-1 prescriptions, with Zepbound as the preferred medication.
Action Required
Before January 1, 2026: Billing team must identify all Harvard Pilgrim and Tufts Health Direct patients currently on weight loss medications and verify their formulary type (Core, Select, ConnectorCare = no coverage; Value, Premium = coverage remains). Update prior authorization workflows to include 6-month behavior modification program requirement for new GLP-1 weight loss prescriptions. Train staff to check formulary before prescribing weight loss medications as existing authorizations will be terminated without grandfathering.