We want to make you aware of upcoming changes in coverage related to weight loss medications, as part of our efforts to provide access to the most appropriate health care options while managing rising pharmacy costs.
These updates include:
- Harvard Pilgrim Health Care Commercial products and Tufts Health Direct will exclude coverage of weight loss medications, including GLP-1 drugs, to treat weight loss and alternative indications — including cardiovascular conditions and other comorbidities.
- Effective on Jan. 1, 2026, this policy will impact Tufts Health Direct and Harvard Pilgrim individual/small group/merged market products utilizing the Core MA, Core NH, Core ME, Core RI, and ConnectorCare formularies. Please keep in mind that for Core NH, Core ME, and Core RI formularies, weight loss drugs are currently excluded from coverage except for alternative indications, and in these cases, the primary change is that as of Jan. 1, 2026 those alternative indications will be excluded from coverage.
- Starting Jan. 1, 2026 (and upon group anniversary date), this policy will impact Harvard Pilgrim large group products (MA, NH, ME, RI) that will be moved to a new Select formulary, which has been designed for cost containment and excludes all weight loss medication coverage.
- This change does not affect GLP-1 medications prescribed for diabetes.
- Some Commercial large groups will be offered the option to buy up to a Premium formulary to include drugs prescribed for weight loss coverage, with Zepbound as the preferred weight loss GLP-1 medication. To receive coverage, members would need to meet the medical necessity criteria for weight loss medications.
- Beginning on Jan. 1, 2026, all fully insured Harvard Pilgrim Commercial plans with weight loss medication coverage will require members who are newly seeking coverage for a weight loss GLP-1 medication to participate in a behavior modification program for 6 months.
- Upon completion, and if the member meets the medical criteria and continues to have weight loss coverage, they will then be eligible to receive coverage for Zepbound as the preferred weight loss GLP-1 medication.
- This program will help members adopt and sustain healthy habits for long-term weight management and include access to weight loss coaching by registered dieticians.
- This requirement applies to members newly starting a weight-loss GLP-1 medication, not members currently on the prescription medication.
- For certain products, such as self-insured accounts, the effective date will be upon the group anniversary date in 2026, and the behavior modification program will be offered as an option.
Determining coverage: formulary and prior authorization information
To determine whether your Harvard Pilgrim Commercial or Tufts Health Direct patient has weight loss drug coverage, please refer to their formulary. Members on the Core, Select, ConnectorCare, and Tufts Health Direct formularies will exclude weight loss medication coverage.
Members who were previously approved for a weight loss medication for weight management or an alternative indication will have their authorization terminated on Jan. 1, 2026, or upon group anniversary. There will be no grandfathering of prior authorizations.
If the member’s product utilizes the Value or Premium formulary for 2026, weight loss medication coverage will remain available, with GLP-1 medications and Contrave subject to prior authorization.
Our utilization management team will provide information on whether the behavior modification program is necessary at the time that the prior authorization determination is made for members newly starting a weight loss GLP-1 medication.
Please note that 2026 formulary selection and coverage may be subject to change upon the group’s anniversary.
Options for members seeking access to weight loss medications
Members who will be affected by this coverage change will be notified by letter at least 60 days prior to the change, and encouraged to discuss options with their primary care physicians and other doctors.
Members may wish to explore prescription discount cards or manufacturer copay assistance programs. Additional information on resources and programs for nutrition and weight management is available on Harvard Pilgrim’s member wellness page.