Currentharvard pilgrim health carePolicy N/A

MassHealth changes to coverage and prior authorization of anti-obesity and GLP-1/GIP medications

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.

Policy Summary

Payerharvard pilgrim health care

PolicyMassHealth changes to coverage and prior authorization of anti-obesity and GLP-1/GIP medications

Policy CodePolicy N/A

Change TypeCoverage restriction and PA process changes

Effective DateJul 1, 202621d

Next Review DateN/A

Key ActionResubmit prior authorizations as needed and attach required documentation for MACE, MASH, or OSA to maintain coverage beyond June 30, 2026.

SourceLink

POLICY UPDATE CHANGES

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.

2026-07-01Effective date drugs for weight loss no longer covered

2026-06-30End date for existing PAs submitted before Feb 17, 2026

6Maximum PA approval length with documentation for MACE/MASH/OSA

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

Listed agents: See Table 1 for affected agents (e.g., benzphetamine; diethylpropion; liraglutide [Saxenda]; orlistat [Xenical]; phendimetrazine; phentermine [Lomaira, Adipex-P]; semaglutide [Wegovy]; tirzepatide [Zepbound])

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

Policy Summary

Payerharvard pilgrim health care

PolicyMassHealth changes to coverage and prior authorization of anti-obesity and GLP-1/GIP medications

Policy CodePolicy N/A

Change TypeCoverage restriction and PA process changes

Effective DateJul 1, 202621d

Next Review DateN/A

Key ActionResubmit prior authorizations as needed and attach required documentation for MACE, MASH, or OSA to maintain coverage beyond June 30, 2026.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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

Operational note: Changes to PA criteria announced in Prescriber eLetter went into effect Feb 17, 2026; documentation (e.g., AHI for OSA, fibrosis stage for MASH) is required for extended approvals.

Affected drugs and MassHealth management list

Listed anti-obesity agents (by drug name)NDC/drug namesNot Covered

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

1–10 of 11

1/2

Antidiabetic GLP-1 and GIP/GLP-1 agents (MassHealth management list)NDC/drug namesCovered

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

Prior Authorization

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

Documentation Required

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

Prior Authorization

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

Denial Risk

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.

Policy changes and important dates

2026-07-01revisedLatest

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.

clarified

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.

clarified

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.

OpenPayer