Currentwellsense_health_planPolicy N/A

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.

Policy Summary

Payerwellsense_health_plan

PolicyMassHealth management of anti-obesity medications

Policy CodePolicy N/A

Change TypeCoverage and prior authorization revisionspreferred drug update

Effective DateJul 3, 2026

Last ReviewJul 3, 2026

Next Review DateN/A

Key ActionResubmit and obtain approval for any prior authorizations for weight-loss medications that were submitted before Feb 17, 2026 to maintain coverage beyond July 2, 2026.

SourceLink

POLICY UPDATE CHANGES

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.

2026-07-03policy change date

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Currentwellsense_health_planPolicy N/A

MassHealth management of anti-obesity medications

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Policy Summary

Payerwellsense_health_plan

PolicyMassHealth management of anti-obesity medications

Policy CodePolicy N/A

Change TypeCoverage and prior authorization revisionspreferred drug update

Effective DateJul 3, 2026

Last ReviewJul 3, 2026

Next Review DateN/A

Key ActionResubmit and obtain approval for any prior authorizations for weight-loss medications that were submitted before Feb 17, 2026 to maintain coverage beyond July 2, 2026.

SourceLink

POLICY UPDATE CHANGES

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.

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.

2026-07-03policy change 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.

Prior authorization requirement: A prior authorization resubmitted and approved for the weight-loss medication is required for coverage beyond July 2, 2026

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.

Step-therapy requirement for tirzepatide: Continued authorization of tirzepatide (Zepbound) beyond July 2, 2026 requires a trial of semaglutide (Wegovy)

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

Listed Anti-Obesity Medications (Table 1)mixed

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

1–10 of 11

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BMI thresholds and conditions

BMI >27 kg/m2 with established cardiovascular diseaseMember has BMI greater than 27 kg/m2 AND established cardiovascular disease to reduce risk of major adverse cardiovascular events (MACE).

BMI >30 kg/m2 with moderate-to-severe OSAMember has BMI greater than 30 kg/m2 AND moderate-to-severe obstructive sleep apnea (OSA).

Metabolic dysfunction-associated steatohepatitis (MASH)Diagnosis of MASH as an accepted indication for continued coverage beyond July 2, 2026.

Members <21 (EPSDT)Members younger than 21 years when use is deemed medically necessary under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements.

Prior Authorization, Documentation, and Step Therapy Requirements

Prior Authorization

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.

Step Therapy

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.

Definitions & Medically Accepted Indications

Medically accepted indications

BMI >27 kg/m2 with established cardiovascular diseaseCoverage allowed when BMI >27 kg/m2 AND established cardiovascular disease to reduce risk of major adverse cardiovascular events (MACE).

BMI >30 kg/m2 with moderate-to-severe OSACoverage allowed when BMI >30 kg/m2 AND moderate-to-severe obstructive sleep apnea (OSA).

Metabolic dysfunction-associated steatohepatitis (MASH)Coverage allowed for members with MASH as a medically accepted indication beyond July 2, 2026.

Members <21 under EPSDTCoverage allowed when medically necessary for members <21 under EPSDT requirements.

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.