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MassHealth management of anti-obesity medications
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Governance of MassHealth coverage, prior authorization, and preferred drug status for anti-obesity medications effective July 3, 2026; affects MassHealth members across FFS, MCOs, PACE, ACPP, PCACO, PCC, SCO, One Care and providers submitting PAs.
Effective July 3, 2026, MassHealth will no longer pay for drugs used only for the treatment of obesity or overweight; a limited set of medically accepted indications remain covered.
Wegovy (semaglutide) will be the sole preferred drug for medically accepted indications other than the explicitly listed exceptions, and Zepbound (tirzepatide) will no longer be preferred effective July 3, 2026.
All prior authorizations for weight-loss medications submitted before February 17, 2026 will be end-dated to July 2, 2026 and must be resubmitted for coverage beyond that date.
Coverage Criteria & Policy Scope
Medically accepted indications for continued coverage
Covered when ALL of the following are met
Medically accepted indication
Specific indications
- BMI >27 with CVD: Body mass index (BMI) >27 kg/m2 AND established cardiovascular disease to reduce the risk of major adverse cardiovascular events (MACE)>27 kg/m2
Indication explicitly listed in policy text.
- BMI >30 with OSA: Body mass index (BMI) >30 kg/m2 AND moderate-to-severe obstructive sleep apnea (OSA)>30 kg/m2
Indication explicitly listed in policy text.
- MASH: Metabolic dysfunction-associated steatohepatitis (MASH)
Indication explicitly listed in policy text.
- EPSDT for members under 21: Member is <21 years old AND treatment is deemed medically necessary under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements
EPSDT requirement explicitly listed in policy text.
All PAs submitted before February 17, 2026 are end-dated to July 2, 2026 and must be resubmitted and approved for paid claims after that date.
Wegovy will be sole preferred drug for other medically accepted indications effective July 3, 2026; Zepbound will no longer be preferred.
Effective July 3, 2026, MassHealth will no longer pay for drugs used only for the treatment of obesity or overweight. This change applies across all MassHealth lines of business (FFS, MCOs, PACE, ACPP, PCACO, PCC, SCO, and One Care) and affects the medications listed in Table 1 of the policy. Providers should transition authorization and treatment plans accordingly because claims for these drugs used solely for obesity or overweight will not be reimbursed after this date.
Use of the listed anti‑obesity medications solely for the treatment of obesity or overweight (i.e., without meeting one of the policy’s specified medically accepted indications) will be considered not covered after July 2, 2026. Providers must document an approved medically accepted indication to support continued coverage beyond that date; otherwise claims submitted for obesity‑only use will be denied.
Listed Medications, BMI Thresholds, and Coding
| benzphetamine | listed Anti-Obesity Medication |
| diethylpropion | listed Anti-Obesity Medication |
| diethylpropion extended-release | listed Anti-Obesity Medication |
| liraglutide (Saxenda) | listed Anti-Obesity Medication |
| orlistat (Xenical) | listed Anti-Obesity Medication |
| phendimetrazine | listed Anti-Obesity Medication |
| phendimetrazine extended-release | listed Anti-Obesity Medication |
| phentermine (Lomaira, Adipex-P) | listed Anti-Obesity Medication |
| phentermine/topiramate extended-release | listed Anti-Obesity Medication |
| semaglutide (Wegovy) | listed Anti-Obesity Medication; sole preferred drug for other medically accepted indications as of July 3, 2026 |
Prior Authorization, Documentation, and Step Therapy Requirements
Resubmit PAs submitted before Feb 17, 2026 (end-dated to Jul 2, 2026)
All prior authorizations (PAs) for weight-loss medications submitted before February 17, 2026 will be end-dated to July 2, 2026 and must be resubmitted and approved to receive paid claims beyond that date.
- End-dated PAs apply regardless of original indication.
- Resubmission and approval are required for claims dated after July 2, 2026.
Require Wegovy trial before Zepbound continued use
Continued authorization of Zepbound (tirzepatide) beyond July 2, 2026 requires a documented trial of Wegovy (semaglutide); Wegovy will be the sole preferred drug for other medically accepted indications effective July 3, 2026.
- PAs for continued Zepbound beyond July 2, 2026 will require trial of Wegovy for all patients.
- Members with an approved Zepbound PA that extends beyond July 2, 2026 will have the PA replaced with an approved Wegovy PA for the remainder of the original authorization; a new Wegovy prescription is required.
Include clinical documentation showing a medically accepted indication
Documentation submitted with PAs must demonstrate a medically accepted indication for continued coverage, such as BMI >27 kg/m2 with established cardiovascular disease, BMI >30 kg/m2 with moderate-to-severe OSA, metabolic dysfunction-associated steatohepatitis (MASH), or EPSDT-approved medical necessity for members under 21.
- Clinical records must support one of the listed medically accepted indications to qualify for coverage beyond July 2, 2026.
- Members in PACE, SCO, or OneCare are expected to seek access via Medicare for these indications.
High denial risk for obesity-only indications after Jul 3, 2026
Claims for drugs used only for the treatment of obesity or overweight will not be paid by MassHealth after July 3, 2026; any PAs not resubmitted and approved to cover dates beyond July 2, 2026 will not be paid.
- Use of listed anti-obesity medications solely for obesity or overweight (without a listed medically accepted indication) is not covered after July 2, 2026.
- Providers risk denial of claims for obesity-only indications effective July 3, 2026 if they do not resubmit and obtain PA approvals.
Definitions & Medically Accepted Indications
Background & Policy Rationale
MassHealth will restrict coverage of drugs when used only for obesity or overweight while preserving coverage for specific medically accepted indications. Covered exceptions include the indications described in the policy (for example, BMI thresholds with comorbid conditions, metabolic dysfunction‑associated steatohepatitis, and medically necessary EPSDT use for members under 21). The policy designates preferred coverage decisions (e.g., Wegovy/semaglutide as the preferred agent for most accepted indications) and provides guidance to assist clinical transitions and prior authorization resubmissions required under the new effective date.
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