As we shared in last month’s issue of Insights and Updates for Providers, effective Oct. 1, 2026, we will no longer cover glucagon-like peptide-1 medications (GLP-1s) when used for weight loss for Tufts Health RITogether members. Prior authorizations beyond Oct. 1 will be end-dated and the members will be notified of the change in coverage. 

Pursuant to the Rhode Island State Fiscal Year 2027 Enacted Budget, Rhode Island Medicaid will no longer cover certain GLP-1 receptor agonists when they are prescribed solely for weight loss, including Foundayo (orforglipron), Saxenda (liraglutide), Wegovy (semaglutide), and Zepbound (tirzepatide).

Wegovy and Zepbound will continue to be covered for other Food and Drug Administration (FDA)-approved indications for respective agents:

  • To reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight for Wegovy injection or tablet
  • To treat noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults for Wegovy injection
  • To treat moderate to severe obstructive sleep apnea in adults with obesity for Zepbound injection

Members who are not using the above listed medications for these indications will have authorizations end-dated to Sept. 30, 2026 and will receive notification of this change. 

GLP-1 receptor agonists that are FDA-approved for treatment of type 2 diabetes mellitus — such as Exenatide, Mounjaro (tirzepatide), Ozempic (semaglutide), Rybelsus (semaglutide), liraglutide (generic Victoza), and Trulicity (dulaglutide) — will continue to be covered with prior authorization. Please note that members who already have authorization for these drugs will not be impacted. Any members with type 2 diabetes mellitus who need to switch to one of these agents will need to submit a new prior authorization request and meet the criteria requirements prespecified on our Pharmacy Medical Necessity Guideline (MNG) titled Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists. 

For members younger than 21 years of age, prior authorization requests will be reviewed for medical necessity in accordance with Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements.

For requests submitted beginning Oct. 1, 2026, members will need to meet our criteria requirements per our Pharmacy MNG titled Pharmacy Products Without Specific Criteria Pharmacy MNG, which will be posted on Oct. 1.