Point32Health is making changes related to coverage of GLP-1 weight management medications, as part of our efforts to provide access to the most appropriate and efficacious health care options while managing health care costs.
Effective July 1, 2025 for members of our Commercial large group, Massachusetts merged market, and Tufts Health Direct plans (Value, Premium, Core Massachusetts, Tufts Health Direct, and Harvard Pilgrim ConnectorCare formularies), Zepbound will be designated as the preferred GLP-1 drug for the treatment of overweight and obesity in members 18 years of age and older.
With this update to our preferred product strategy, the medications Wegovy and Saxenda will be moved to non-formulary for the treatment of overweight or obesity in adults. As a result:
- Members who are 18 and older and currently receiving Wegovy or Saxenda for the treatment of obesity or overweight will be required to switch to Zepbound.
- Prior authorizations for Wegovy and Saxenda will be end dated for June 30, 2025. Prescribers will need to issue a new prescription for Zepbound for these members if continued treatment of obesity or overweight is needed.
Notable exceptions
Please note that Wegovy and Saxenda will remain covered with prior authorization for members under 18 years of age. A new prior authorization will not be needed if adolescents have an approval for Wegovy or Saxenda prior to July 1, 2025.
In addition, Point32Health will continue to cover Wegovy to reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight. A new prior authorization will need to be submitted to specify that Wegovy is needed for this indication.
Transitioning members to Zepbound
To help with the transition, all impacted members 18 and older who were approved for Wegovy or Saxenda for obesity or overweight treatment and had an approval beyond June 30, 2025, will automatically receive a new authorization for Zepbound to be covered at the pharmacy. The Zepbound authorization will have the start date of May 1, 2025 and will have the same end date as the current Wegovy/Saxenda authorization for plans with continued weight loss drug coverage. When it’s time to renew the authorization, members must meet the reauthorization criteria with provider submission of starting and follow-up weights.
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 Non-Formulary Exceptions and Weight Loss Medications. Additional information on resources and programs for nutrition and weight management are available on Harvard Pilgrim’s wellness page.