MassHealth changes to coverage and prior authorization of anti-obesity and GLP-1/GIP medications
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Notifies payers/providers that MassHealth will stop covering drugs used for obesity/overweight effective July 1, 2026, describes which agents are affected, exceptions for certain medically accepted indications, and prior authorization (PA) handling and timelines.
MassHealth will no longer cover drugs used for the treatment of obesity or overweight effective July 1, 2026; listed agents will not be covered for weight loss.
GLP-1/GIP agents will remain coverable beyond June 30, 2026 only for specified medically accepted indications (MACE risk reduction, MASH, moderate-severe OSA) with documentation and approved PA.
PAs submitted between Feb 17, 2026 and June 30, 2026 for weight-loss indications will be reviewed but, if approved for obesity/overweight without documented comorbidities, will expire June 30, 2026.
Which agents are covered and when
Coverage for Anti-Obesity Agents
Anti-obesity/weight-loss agents listed below will not be covered for weight loss beginning July 1, 2026. Exceptions exist for other medically accepted indications as specified.
ALL of the following
- Drug is used for the treatment of obesity or overweight
MassHealth will no longer cover these indications for listed agents effective 7/1/2026
Exceptions — GLP-1/GIP agents covered for other medically accepted indications
GLP-1 or GIP/GLP-1 medications will be covered beyond June 30, 2026 when ALL of the following apply:
ALL of the following
Approved indications (any one qualifies)
- Body Mass Index (BMI) > 27 kg/m2 AND established cardiovascular disease to reduce risk of major adverse cardiovascular events (MACE)
- Metabolic dysfunction-associated steatohepatitis (MASH)
Documentation of fibrosis stage required for extended approval
- BMI > 30 kg/m2 AND moderate to severe obstructive sleep apnea (OSA)
Apnea–hypopnea index (AHI) score required for extended approval
- Prior authorization is approved and appropriate documentation is attached
If documentation not attached, PA will be end-dated to June 30, 2026
Prior Authorization submission windows and expirations
Rules governing PA submissions and expirations based on submission date and indication:
ANY of the following
ALL of the following
- PAs submitted before Feb 17, 2026
These will be end-dated to June 30, 2026 regardless of indication; must be resubmitted to receive paid claims beyond July 1, 2026
ANY of the following
- If indication = obesity or overweight without documented comorbidities
Approved PAs will expire June 30, 2026
- If indication = diabetes or prediabetes
Approvals will expire June 30, 2026; for continued coverage beginning July 1, 2026 members should be switched to an antidiabetic GLP-1
- If indication = MACE, MASH, or OSA with documentation attached
PAs will be reviewed and may be approved for up to six months
Pediatric review
Special review requirement for members under 21 years of age:
ALL of the following
- All requests for members under 21 will be reviewed for medical necessity in accordance with EPSDT requirements
Affected drugs and MassHealth management list
| benzphetamine | Anti-Obesity Agent |
| diethylpropion | Anti-Obesity Agent |
| diethylpropion extended-release | Anti-Obesity Agent |
| Saxenda (liraglutide) | Anti-Obesity Agent |
| Xenical (orlistat) | Anti-Obesity Agent |
| phendimetrazine | Anti-Obesity Agent |
| phendimetrazine extended-release | Anti-Obesity Agent |
| Lomaira (phentermine) | Anti-Obesity Agent |
| Adipex-P (phentermine) | Anti-Obesity Agent |
| Wegovy (semaglutide) | Anti-Obesity Agent |
| Ozempic (semaglutide injection) | PD/POS, GLP-1 Agonist; managed |
| Bydureon Bcise (exenatide XR) | Non-Preferred (exenatide extended-release auto-injection) |
| Trulicity (dulaglutide) | PD/POS, GLP-1 Agonist; managed |
| Exenatide (Byetta/exenatide) | Non-Preferred |
| Victoza (liraglutide) | BP/POS, GLP-1 Agonist; managed |
| Rybelsus (oral semaglutide) | Non-Preferred (semaglutide tablet) |
| Mounjaro (tirzepatide) | PD/POS, GIP and GLP-1 Agonist; managed |
What providers must do
Resubmit prior authorizations or expect end-dating
PAs submitted before February 17, 2026 will be end-dated to June 30, 2026 and must be resubmitted to receive paid claims for dates of service on or after July 1, 2026. PAs submitted between February 17 and June 30, 2026 will be processed by the submitted indication but may still expire on June 30, 2026 depending on indication and documentation provided.
- All listed anti-obesity agents
- Antidiabetic GLP-1 and GIP/GLP-1 agents
Attach documentation for MACE, MASH, OSA
For PAs seeking continued coverage beyond June 30, 2026 for MACE, MASH, or moderate–severe OSA, attach objective documentation certifying severity (for example, AHI score for OSA, fibrosis stage for MASH, or documentation of established cardiovascular disease for MACE). Without this documentation the PA will be end-dated to June 30, 2026.
- Example documentation: apneahypopnea index (AHI) score for OSA; fibrosis stage for MASH; clinical documentation of established CVD for MACE
Diabetes/prediabetes approvals require switching for continued coverage
Approvals for diabetes or prediabetes will expire on June 30, 2026; to ensure continued coverage beginning July 1, 2026, members should be switched to an antidiabetic GLP-1 that is listed on the MassHealth Drug List.
- Antidiabetic GLP-1 and GIP/GLP-1 agents
Risk of end-dating/denial if documentation missing
If the required objective documentation certifying severity for MACE, MASH, or OSA is not attached to the PA, the PA will be end-dated to June 30, 2026, creating risk of denial for coverage beyond that date.
- Attach supporting objective tests (e.g., AHI for OSA, fibrosis stage for MASH, documentation of established CVD) to avoid end-dating.
Clinical and administrative context
MassHealth is updating coverage consistent with anticipated regulation 130 CMR 406.413(B). Effective July 1, 2026, MassHealth will no longer cover medications when they are used specifically for the treatment of obesity or overweight; the agents listed as anti‑obesity drugs (for example, benzphetamine; diethylpropion and its extended‑release form; Saxenda [liraglutide]; Xenical [orlistat]; phendimetrazine and its extended‑release form; Lomaira and Adipex‑P [phentermine]; Wegovy [semaglutide]; and Zepbound [tirzepatide]) will not be covered for weight loss use.
GLP‑1 and GIP/GLP‑1 agents used for diabetes and other specified medically accepted indications will continue to be managed on the MassHealth Drug List. These antidiabetic GLP‑1 and GIP/GLP‑1 medications remain subject to prior authorization (PA) requirements and may have non‑preferred designations for certain products; members receiving GLP‑1/GIP agents for diabetes or other covered indications should follow the MassHealth Drug List and PA criteria for those therapies.
Existing prior authorizations submitted before February 17, 2026, will be end‑dated to June 30, 2026 and must be resubmitted to obtain paid claims beyond July 1, 2026. PAs submitted between February 17, 2026 and June 30, 2026 will be processed based on the submitted indication but, if approved for obesity/overweight without documented qualifying comorbidities, will expire on June 30, 2026.
GLP‑1/GIP agents will remain coverable beyond June 30, 2026 only when used for other medically accepted indications with an approved PA and required supporting documentation (examples: BMI > 27 kg/m2 with established cardiovascular disease for MACE risk reduction; MASH with documented fibrosis stage; or BMI > 30 kg/m2 with moderate–severe OSA documented by AHI). When documentation for MACE, MASH, or OSA is attached, PAs may be approved for up to six months; without that documentation, the PA will be end‑dated to June 30, 2026.
Defined terms
Policy changes and important dates
MassHealth will no longer cover drugs used for the treatment of obesity or overweight effective July 1, 2026; listed agents will not be covered for weight loss. Existing prior authorizations submitted before Feb 17, 2026 will be end-dated to June 30, 2026 and must be resubmitted for coverage beyond July 1, 2026.
PAs for MACE, MASH, or OSA will be reviewed and may be approved for up to six months if appropriate documentation is attached; if documentation is not attached, PAs for these indications will be end-dated to June 30, 2026.
Approvable PAs for diabetes or prediabetes will expire on June 30, 2026; for continued coverage beginning July 1, 2026, members should be switched to an antidiabetic GLP-1 available on the MassHealth Drug List.
At-a-glance dates and thresholds
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