GLP-1 coverage

Why are you changing your coverage of GLP-1s?

Like other health plans across the country, Mass General Brigham Health Plan has been closely monitoring the increasing use and cost of GLP-1 medications. This change is part of an integrated approach to providing affordable premiums, while supporting our members’ health needs.

What is changing in your coverage of GLP-1s?

Coverage for GLP-1s approved to treat type 2 diabetes is not changing. Starting on January 1, 2026, we will no longer provide coverage of GLP-1s that share an indication of obesity or weight management for individual commercial members and small employers.

Employer accounts with 50 or more enrolled subscribers will have the option to add coverage of GLP-1s for weight management when their plans renew in 2026.

When will this policy update be in effect?

This coverage change is effective on January 1, 2026, for individual and small groups and upon renewal in 2026 for large groups.

Which specific GLP-1 medications will be covered and for what indications?

Starting January 1, 2026, coverage will exclude GLP-1s for conditions other than type 2 diabetes. Coverage for GLP-1s approved to treat type 2 diabetes is not changing. This includes Ozempic, Mounjaro, Trulicity, and others. Please note that these medications will continue to require prior authorization. For additional information, please review our Medical and Pharmacy Policies.

Will all Mass General Brigham Health Plan members be impacted by this change?

This change applies to fully insured commercial members. Coverage for GLP-1s in 2026 will vary depending on a member’s plan type and employer:

• Commercial: Individual and small group members with prescription drug coverage with Mass General Brigham Health Plan will have coverage of GLP-1s only for type 2 diabetes. Employers with 50 or more enrolled subscribers have the option to add GLP-1s for weight management when their plans renew in 2026.

• Medicare Advantage: The Centers for Medicaid and Medicare Services (CMS) does not allow coverage of GLP-1s for weight loss for Medicare and Medicare Advantage members.

• Medicaid: We follow MassHealth guidelines that include coverage of diabetes and a preferred GLP-1 treatment for weight loss.

How can I purchase a GLP-1 medication that is no longer covered?

The cost depends on several factors, including which GLP-1 medication you take. Some cost less than others, so check with your doctor or pharmacist about pricing. Additionally:

• Patient assistance programs and pharmacy discount services/platforms can help lower costs.
• Some pharmaceutical manufacturers provide cost assistance through patient assistance programs or prescription savings cards to help cover part of the drug cost. You can get that information from the manufacturer websites.
• If you have a health savings account (HSA) and/or flexible spending account (FSA), you may be able to use these funds to help pay for your medication.

Do you cover other medications for weight loss?

We encourage members to speak to their doctor for questions about resources and medications to support their weight loss journey. Please note, we cover other weight loss medications for commercial members:

• Alli (orlistat)*
• Contrave (naltrexone/bupropion) *
• Phentermine
• Qsymia (phentermine/topiramate extended-release)

*Require a prior authorization. 

How will impacted employers and members know about this change?

We are speaking with employers about their coverage as part of the annual renewal process. We will also be sending notices to impacted members about their coverage and alternative options for wellness support.

How are you supporting members with their health and wellness goals?

We are pleased to offer comprehensive benefits to help members achieve their health and wellness goals. Our programs are designed for long-term success by meeting members where they are on their health journeys.

Where can members enroll in your health and wellness programs?

Members should speak to their doctors about these options. For more support, members can contact our Customer Serivce team at 866-414-5533 or HealthPlanCustomerService-Members@mgb.org.