MassHealth Pharmacy and Medical Benefit Updates (Effective 7/1/2026)
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Governs MassHealth pharmacy and selected medical benefit coverage changes effective July 1, 2026, including formulary status, prior authorization, step therapy, quantity limits, and preferred product updates affecting prescribers, pharmacists, and plan administrators.
MassHealth will no longer cover medications used solely for weight loss, including GLP-1 agents, effective July 1, 2026.
Wegovy (semaglutide) designated as the sole non-diabetic GLP-1 preferred medication for medically accepted non-weight-loss conditions with restrictions.
Multiple product-specific prior authorization, step-through, quantity limit, and age-indication updates across many therapeutic classes effective 7/1/2026.
UPCR and proteinuria thresholds for IgA nephropathy agents updated to >= 0.5.
Coverage Criteria & High-level Decisions
Major coverage criteria
Notable coverage stances effective 7/1/2026:
Members with existing prior authorizations can fill through 6/30/2026; diabetic patients requiring a diabetic GLP-1 require a new written prescription for an appropriate diabetic medication
Zepbound (tirzepatide) is non-preferred and requires a step-through with Wegovy for OSA
Clinical rationale required if Wegovy is not used for EPSDT requests
Examples include requirement for Nemluvio prior to Cibinqo or Rinvoq in atopic dermatitis, and Dupixent/Fasenra required steps for multiple asthma/CRwNP agents
Applies to all IgAN agents; step-throughs with listed alternatives may also be required where specified
Medications used solely for weight loss will no longer be covered by MassHealth effective 7/1/2026. This exclusion specifically includes GLP-1 agents prescribed for weight loss, including off‑label use of diabetic GLP‑1s, as well as oral weight‑loss medications. The policy applies to all MassHealth members, including those in the Mass General Brigham ACO; members will be notified of the change before the effective date.
Use of GLP‑1 agents solely for weight loss is considered not covered / medically unnecessary under MassHealth beginning 7/1/2026. Requests for coverage of GLP‑1 therapy when the only indication is weight loss will be denied after that date unless another covered medical indication is documented.
Coding, Identifiers, and Clinical Thresholds
| 93815-0715-77 | Freestyle Precision Neo test strip |
| 93815-0715-79 | Freestyle Precision Neo test strip |
Provider Requirements, Prior Authorization, and Documentation
Prior Authorization Required
Prior Authorization is required for numerous listed drugs. PA applies to both brand-name products and FDA “A”-rated generics. Prescribers must obtain PA before dispensing affected medications. Missing PA may result in claim denials or delayed therapy.
- Applies to drugs listed on the formulary as requiring PA.
- PA requirement effective 2026-07-01 for changes noted in this update.
Step-through Trial Enforcement
Step-through (step-therapy) trials will be enforced per the updated criteria. Requests that do not document required trials of preferred agents (or provide clinical rationale for bypassing them) will be subject to denial. This includes initial and reauthorization requests where step-throughs are specified.
- Example: Zepbound (tirzepatide) requires a documented trial of Wegovy (semaglutide) for moderate to severe obstructive sleep apnea (OSA).
- Example: For certain biologics (e.g., Exdensur, Tezspire, Nucala), documented trials with preferred agents such as Dupixent and Fasenra (or other listed preferred agents) are required.
Required Step-through Trials
Specific step-through requirements must be met and documented on PA requests. For non‑diabetic GLP-1 and related agents, Wegovy (semaglutide) is the preferred non‑diabetic GLP-1 and must be tried before non‑preferred GLP-1 agents for indicated conditions. For members aged 12–21 new to GLP-1 therapy, additional step-through with phentermine is required in addition to Wegovy when applicable. EPSDT-related approvals must include clinical rationale if Wegovy is not used.
- Wegovy will be the sole non-diabetic GLP-1 preferred medication for specified indications (e.g., BMI >27 kg/m² with ASCVD, MASH; BMI >30 kg/m² with moderate–severe OSA).
- Zepbound (tirzepatide) is non-preferred for OSA and requires prior trial/failure of Wegovy.
- Members 12–21 who qualify under EPSDT: step-through with phentermine required for those new to GLP‑1 therapy, plus Wegovy trial; other <21 requests reviewed per EPSDT.
- Step-through requirements apply to both initial and reauthorization requests when specified.
Supporting Clinical Documentation Required
PA approvals may require supporting clinical documentation to demonstrate medical necessity and fulfillment of step-through or other criteria. Provide validated rating scales, laboratory evidence, current prescriptions, and medical records as applicable. Incomplete documentation may lead to denial or request for additional information.
- For diabetes/prediabetes: provide a new written prescription/documentation from the prescriber when a diabetic GLP‑1 is indicated.
- For therapies like Spravato: include current assessment using validated depression rating scales (e.g., MADRS, HAM-D, PHQ-9, BDI) and documentation of prior trials (e.g., mood stabilizer).
- Provide lab evidence where required (e.g., relevant A1c, UPCR thresholds) or other condition‑specific labs noted in criteria.
- Document trials and failures of preferred agents with dates, doses, and clinical rationale if bypassing preferred agents.
Initial Therapy Requirements
Initial Therapy Requirements
Examples of initial therapy constraints:
Novolin products will require prior authorization in affected settings; age-based exceptions may apply
Applies to both initial requests and reauthorizations; documentation of eosinophilic phenotype may be required for severe asthma
For OSA, Zepbound (tirzepatide) requires a prior trial of Wegovy; EPSDT rules require phentermine step-through for members 12–21 new to GLP-1 therapy
Continuation / Reauthorization Rules
Continuation / Reauthorization rules
Reauthorization constraints added for some agents
Example: dosing schedules (e.g., twice-weekly) have maximum durations (policy clarifies limits such as a 6-month maximum for higher frequency regimens)
Continuation is restricted in post-gene therapy patients per updated criteria
Example: Nucala and Tezspire criteria updated to require trials with Dupixent (and Fasenra for eosinophilic asthma); Fasenra reauthorization interval standardized to 12 months
Step Therapy Tables and Required Trials
| Scenario | Required prior step(s) / preferred agent(s) | Notes |
|---|---|---|
| Non‑diabetic GLP‑1 requests (e.g., tirzepatide/Zepbound) | Wegovy (semaglutide) must be tried first (sole preferred non‑diabetic GLP‑1) | Zepbound (tirzepatide) is non‑preferred and will require step‑through with Wegovy for moderate to severe obstructive sleep apnea; EPSDT cases require rationale if not using Wegovy; ages 12–21 new to GLP‑1 also require phentermine step in addition to Wegovy |
| Asthma/allergy biologics (e.g., Cibinqo, Rinvoq, Tezspire, Nucala) | Step‑through with preferred agents such as Dupixent and Fasenra required (Nemluvio required as a step for Cibinqo/Rinvoq in AD when applicable) | Applies to initial and reauthorization requests; Tezspire and Nucala criteria updated to require Dupixent ± Fasenra trials for indicated populations; Nemluvio preferences adjusted per indication |
| Ustekinumab class (newly added biosimilars) and other specialty biologics | Preferred biosimilars (Starjemza, unbranded ustekinumab‑aauz) favored per formulary; step‑throughs with listed preferred agents required where specified | Starjemza and certain unbranded ustekinumabs designated preferred; some previously preferred brands (Imuldosa, Pyzchiva, Steqyma) are no longer preferred—step sequences updated accordingly |
| Agent / Scenario | Required trial before coverage | Notes |
|---|---|---|
| Novolin N (where specified) | Trial of Humulin N required prior to Novolin N | Applies to step‑through trials for insulin NPH products as updated effective 7/1/2026 |
| Humulin 70/30 / Novolin 70/30 scenarios | Trial of Humulin 70/30 required prior to Novolin 70/30 | Similar step‑through requirement mirrors NPH insulin updates |
| Hyrnuo (lung cancer agent) | Step‑through trial with a first‑line systemic therapy required prior to coverage | Hyrnuo will be added to pharmacy benefit with PA and QL and requires failure of first‑line systemic therapy |
Quantity Limits by Product
Site-of-Care and Medical Benefit Notes
Medical‑benefit only agents require PA and billing to infusion/medical site
Some high‑cost or injectable agents will be covered under the medical benefit only and require prior authorization (e.g., specified monoclonal antibodies and oncology immunotherapies added to the medical benefit).
- Confirm site-of-care billing: if the drug is listed as medical‑benefit only, submit PA for infusion/administration under the medical benefit.
- Examples include Exdensur and Unloxcyt and other agents added to medical benefit with PA requirements.
Biosimilar Preferences
Use preferred ustekinumab biosimilars (Starjemza, unbranded ustekinumab‑aauz) or document rationale
Starjemza and unbranded ustekinumab‑aauz are designated preferred biosimilars for listed ustekinumab products; prior authorization and product mapping must reflect the preferred biosimilar choices when requesting ustekinumab‑class agents.
- Preferred biosimilars: Starjemza and unbranded ustekinumab‑aauz.
- Imuldosa, Pyzchiva, and Steqyma will no longer be preferred—use preferred biosimilars or provide clinical rationale for non‑preferred selection.
Background and Rationale
This update reorganizes formulary preferences and access controls to align benefit coverage with clinical indications and cost‑preferred products. A central change is the exclusion of medications used solely for weight loss (notably GLP‑1s) effective 7/1/2026, while preserving coverage for GLP‑1s and other agents when prescribed for other medically accepted conditions and when clinical criteria are met. Providers should plan for member notification and for transitioning members with existing prior authorizations through the specified run‑out period.
Definitions and Formulary Designations
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