Effective May 1, 2026 for Harvard Pilgrim Health Care Commercial and Tufts Health Direct members on our Premium, Select, Value, Core Massachusetts, Tuft Health Direct, and Value ConnectorCare formularies, the automated step therapy program will be removed for diabetic GLP-1 and GIP/GLP-1 medications.

Currently, step therapy is applied at the point of service; if a member requesting a diabetic GLP-1 or GIP/GLP-1 medication at the pharmacy has a prior claim for an oral hypoglycemic agent from within the previous 365 days, the claim will automatically pay. Prior authorization would only be required in the event that there is no evidence of a paid claim for an oral hypoglycemic agent. 

As of May 1, however, this automated step therapy program will no longer apply. Prior authorization will be required for all members with the products/formularies referenced above for diabetic GLP-1 and GIP/GLP-1 medications (e.g., Bydureon BCise, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity). The prior authorization criteria, intended to reduce or prevent off-label use for weight loss, will specify that coverage is only available for these members if they have a diagnosis of type 2 diabetes and have a trial and failure of a 30-day supply — or are currently taking — an oral hypoglycemic agent. 

Members impacted by this update will be notified at least 60 days prior to the change. For coverage of diabetic GLP-1 and GIP/GLP-1 medications, prescribing providers must submit a request through the typical medical review process subject to our Pharmacy Medical Necessity Guidelines for Incretin Mimetics. 

Additionally, as a reminder, the coverage changes we’ve previously announced related to medications including GLP-1 drugs to treat weight loss and alternative indications are now in effect as of Jan. 1, 2026.