Point32Health is implementing the following additional Pharmacy updates for the 2025 plan year.
2025 formularies
In an effort to support member needs by market, manage costs, and implement state-specific regulatory requirements by formulary, Point32Health has created market-specific Small Group/Individual/Merged Market (SG/Ind/MM) formularies for 2025. Maine and Rhode Island SG/Ind/MM will have new formularies upon plan renewal in 2025, while New Hampshire and Massachusetts Merged Market members will remain on their existing formulary.
Members experiencing a change in coverage will be notified at least 60 days prior to the change, and the 2025 formularies for SG/Ind/MM are now available on our provider website. The chart below lists the 2025 formularies.
| State/Market | 2025 formulary |
| RI Small Group | Core RI (new formulary) |
| Maine Merged Market | Core ME
(new formulary) |
| NH Small Group/Individual | Core NH (no change) |
| MA Merged Market | Core MA (formulary name change only) |
| Direct (MA) | Tufts Health Direct (no change) |
| ConnectorCare | Value ConnectorCare (no change) |
Weight loss prescription drugs and diabetic GLP-1 coverage for Core Maine, Core New Hampshire, and Core Rhode Island formularies
On or after Jan. 1, 2025, small group and individual market Commercial members in Maine (merged market members), New Hampshire (small group and individual market members), and Rhode Island (small group members) will no longer have coverage for prescription weight loss medications (e.g., Contrave, phentermine), including GLP-1 drugs (e.g., Saxenda, Wegovy). This change will occur upon the plan’s anniversary date. It becomes effective in Maine and Rhode Island upon anniversary when members move to the new Core Maine or Core Rhode Island formularies. The change becomes effective on Jan. 1, 2025 in New Hampshire as part of annual (Core) formulary changes.
Members who were previously approved for a weight loss medication will have their authorization terminated upon plan renewal in 2025. There will be no grandfathering of prior authorizations. On or after Jan. 1, 2025 for Core New Hampshire and upon plan renewal in 2025 for Core Maine and Core Rhode Island formularies, diabetic GLP-1 drugs (e.g., Ozempic, Mounjaro) will require prior authorization to reduce and prevent off-label use for weight loss. Prior authorization for the diabetic GLP-1 drugs will only be covered if members have a diagnosis of type 2 diabetes and if members have a trial and failure of a 30-day supply or are currently taking an oral hypoglycemic agent.
Utilizing members will be notified at least 60 days prior to the change. To request an exception, the prescribing provider must request coverage through the medical review process subject to our Pharmacy Medical Necessity Guidelines for Incretin Mimetics. Additional information on resources and programs for nutrition and weight management are available on Harvard Pilgrim’s wellness page.
Anti-obesity coverage changes for MassHealth
The MassHealth Pharmacy Program is announcing changes to the management of anti-obesity medications. Below is a summary of the upcoming changes:
Effective Oct. 1, 2024, Zepbound is also designated as a preferred drug for the treatment of overweight and obesity. With this update, Zepbound no longer requires a trial with Wegovy or Saxenda for prior authorization approval.
Effective Jan. 1, 2025, Wegovy and Saxenda will be non-covered agents for the treatment of obesity or overweight in adults.
- All MassHealth members ≥18 years of age receiving Wegovy or Saxenda for the treatment of obesity or overweight will be required to switch to Zepbound.
- All prior authorizations for Wegovy and Saxenda will be end dated for Dec. 31, 2024, and members will be expected to transition to Zepbound.
- Wegovy and Saxenda will remain covered with prior authorization for members ≥12 to <18 years of age. No new prior authorizations will be needed if adolescents have an approval for Wegovy or Saxenda prior to Jan. 1, 2025.
- MassHealth will continue to cover Wegovy for the indication of reduction of the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight. A new prior authorization may need to be submitted to specify that Wegovy is needed for this indication.
Effective Jan. 6, 2025:
- Generic phentermine will be available without prior authorization for all MassHealth members >12 years of age and Lomaira will be available without prior authorization for MassHealth members >12 to <17 years of age.
- All requests for a GLP-1 for the treatment of obesity or overweight for members not already stable on GLP-1 therapy will require a step through phentermine, with or without topiramate.
- The following topiramate formulations are available without prior authorization for members six years of age and older: brand name Qudexy XR and generic topiramate sprinkle capsule and tablet.
- Members already stable on GLP-1 therapy will not require this step through phentermine. For all new starts on Zepbound, prior authorization will require inadequate response, adverse reaction, or contraindication to phentermine with or without topiramate
To aid in transitioning, all MassHealth members ≥18 years of age approved for Wegovy or Saxenda for the treatment of obesity or overweight that had an approval duration beyond Dec. 31, 2024, will automatically have a new prior authorization in place to allow Zepbound to pay at the pharmacy. The Zepbound prior authorization will expire six-months after the most recent Wegovy or Saxenda prior authorization was approved. Recertification prior authorization for Zepbound will be required and will be reviewed using baseline weight.
The MassHealth Drug List, including Therapeutic Class Table 81 (outlining the coverage status and PA criteria for anti-obesity agents, including weight-related comorbidities) and the Anti-Obesity Agents PA form, will be updated to reflect these changes. The MassHealth Drug List can be found on the MassHealth Pharmacy Program site.
Adalimumab
Effective Jan. 1, 2025, Humira will remain the preferred adalimumab product for Harvard Pilgrim Commercial, Tufts Health Plan Commercial, and Tufts Health Direct, and all available adalimumab biosimilars will be moved to non-formulary status.
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