The increasing prevalence of obesity and its associated health complications has heightened the importance of effective weight-loss medications. Wegovy (semaglutide), a medication approved by the FDA, has demonstrated notable success in aiding individuals struggling with obesity. A frequently asked question among patients in New England and nearby areas is, "Does Harvard Pilgrim Health Care cover Wegovy?" This article provides a detailed overview of Harvard Pilgrim's coverage policies for Wegovy, including eligibility criteria, prior authorization requirements, potential costs, and alternative options if your plan does not include this medication.
Understanding Wegovy
Wegovy is a prescription medication that contains semaglutide, which mimics the GLP-1 hormone. The Food and Drug Administration (FDA) approved Wegovy in 2021 for chronic weight management in adults who have:
- A body mass index (BMI) of 30 or higher (obesity)
- A BMI of 27 or higher with at least one weight-related condition such as high blood pressure, type 2 diabetes, or high cholesterol
Clinical trials have shown that Wegovy, when combined with a reduced-calorie diet and increased physical activity, can help patients achieve up to 15% body weight loss, surpassing the success rates of previous weight-loss medications.
Harvard Pilgrim Health Care: An Overview
Harvard Pilgrim Health Care (HPHC), operating under Point32Health, provides health insurance to individuals, families, and employers in Massachusetts, Maine, Connecticut, and New Hampshire. Harvard Pilgrim offers various health plans, including HMO, PPO, and POS options, each with different levels of prescription coverage.
Coverage for medications like Wegovy depends on several factors:
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- The specific health plan you’re enrolled in
- Whether anti-obesity medications are included in the formulary
- Whether you meet Harvard Pilgrim’s medical necessity criteria
Wegovy Coverage Under Harvard Pilgrim
Coverage for Wegovy under Harvard Pilgrim Health Care is conditional. It may be covered if the medication is listed on the plan’s formulary and if you meet specific clinical requirements. However, coverage can vary based on:
- Your employer group plan
- Whether your plan’s pharmacy benefit includes weight-loss medications
- Medical necessity documentation provided by your doctor
If a plan excludes anti-obesity medications, Wegovy will not be covered, regardless of your diagnosis or physician’s recommendation.
Eligibility and Coverage Criteria
If your Harvard Pilgrim plan includes coverage for anti-obesity medications, you may qualify for Wegovy coverage if:
You meet BMI criteria:
- BMI ≥ 30 (obese)
- BMI ≥ 27 with a weight-related comorbidity (e.g., diabetes, hypertension, dyslipidemia)
You’ve attempted other treatments: You must demonstrate a history of unsuccessful weight-loss attempts through diet, exercise, or other medications. Medical records should demonstrate that the patient has gained or maintained weight following or during previous treatments with other anti-obesity medications, if applicable.
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You receive a doctor’s prescription and medical documentation: Your physician must provide a clinical rationale for why Wegovy is medically necessary.
You undergo prior authorization: Harvard Pilgrim requires your doctor to complete a prior authorization form before the medication is approved.
You’re over 18 years of age: Wegovy is approved for adults; pediatric use requires separate approval.
Most Harvard Pilgrim plans that offer coverage for Wegovy require prior authorization (PA). Coverage requires prior authorization and proof of medical necessity.
How to Determine Wegovy Coverage
To determine if your Harvard Pilgrim plan covers Wegovy:
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- Check your plan’s formulary for drug inclusion.
- Contact Harvard Pilgrim’s member services directly for confirmation.
Navigating Coverage Changes in 2026
To keep health plans affordable, most 2026 plans will exclude pharmacy coverage for weight loss medications, including GLP-1s approved for conditions other than diabetes. Harvard Pilgrim is informing its provider network about these changes.
Review any 2026 plan materials you and your covered family members receive from your employer or from Harvard Pilgrim. If you and your doctor decide that weight loss medications are necessary, and your 2026 plan does not include coverage, you’ll need to pay for these drugs out of your own pocket. Prescription discount cards or manufacturer copay assistance programs may be available to help with the cost of weight loss medications. Ask your pharmacy or doctor for details. Speak with your doctor if you have questions about these changes or other ways to help support your weight management needs.
What to Do If Wegovy Isn’t Covered
If Wegovy is not covered by your Harvard Pilgrim plan, consider the following options:
- Appeal the denial: You can appeal the denial, providing further evidence of medical necessity.
- Apply for manufacturer discounts: Explore manufacturer discount programs that may help lower the cost of Wegovy. Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs.
- Explore alternative medications: Discuss alternative weight-loss medications with your doctor that might be covered by your plan, such as Saxenda, Contrave, or Qsymia.
- Consider joining a qualified weight management program: Members may be eligible to be reimbursed for fees paid toward a qualified weight management program. You can request reimbursement for up to 12 weeks of membership per calendar year (i.e., January-December) in total for the WW® (Weight Watchers) digital program or workshop or for a hospital-based weight management program for yourself, your dependents or both. Program eligibility and benefits may vary by employer, plan and state. Check with your employer or call Member Services at 888-333-4742 (TTY: 711). Please submit the form before the end of the calendar year following the year when you took part in the weight management program. For example, if you took part in a program in 2024, you’ll need to submit your form by the end of 2025. If you have coverage through an employer, the deadline for submitting your reimbursement may be different. It can take up to eight weeks to receive your reimbursement check after you submit your request.
Prior Authorization Process
Most Harvard Pilgrim plans require prior authorization for Wegovy, which your healthcare provider must submit. Approval typically takes between 3 to 10 business days, depending on whether the request is standard or urgent. For a faster decision in MA, ME, NH & RI, your provider must provide the necessary medical information with the initial request for an exception.
Your provider may request an expedited exception when you could seriously jeopardize your life, health or ability to regain maximum function if there is a delay in treatment, or if you are undergoing a current course of treatment using a non-covered drug. We will notify you of a decision no later than 24 hours after receiving your expedited request.
To start the exception process, members can complete an exception request form. Providers can start the exception process by completing a formulary exception request form and faxing it to 616-673-0988. A statement from your provider explaining why an exception is medically necessary, including why a covered drug is not as effective as the requested drug, is needed.
Your exception request will be considered by pharmacists and other clinicians as appropriate. If your request is denied, you will be notified why and how you can request an appeal of the decision.
Conditions Qualifying for Wegovy Coverage
Wegovy is typically covered for adults with:
- A BMI ≥ 30
- A BMI ≥ 27 with conditions like diabetes, hypertension, or dyslipidemia
Employer Influence on Coverage
Employer-sponsored health plans can choose to include or exclude weight-loss medications in their benefit design.
Wegovy for Diabetes Treatment
Wegovy is approved for weight management, not diabetes. However, Mounjaro or Ozempic may be covered for diabetes under specific plans.
Point32Health's Coverage Changes for 2025
Point32Health, the owner of Harvard Pilgrim Health Care and Tufts Health Plan, is significantly scaling back its coverage of costly GLP-1 drugs when used for weight loss beginning next year, following a similar move by Blue Cross Blue Shield of Massachusetts.
Starting Jan. 1, Point32Health will dramatically change how and when it pays for Zepbound - the insurer’s preferred GLP-1 weight-loss drug - when used to treat overweight or obesity. For patients who purchase their plans from the Massachusetts Health Connector or are insured through a workplace with 99 or fewer employees, coverage will end completely for the popular but pricey drug for weight loss altogether.
Larger employers, whose Harvard Pilgrim plans cover 100 or more employees, can opt to pay more to continue coverage of Zepbound for weight loss. However, if these employers are “fully insured,” they will have to mandate that employees looking to get on Zepbound first complete a six-month “behavioral modification program,” involving coaching from dietitians through the Boston-based company Good Measures. Members who are already prescribed a GLP-1 drug whose employers opt to continue coverage will not have to undergo the Good Measures program. The program will also be optional for large employers that are “self-insured.”
Coverage will continue unchanged for those insured by Tufts Health Plan through MassHealth, “as required by MassHealth regulations".
Earlier this year, Point32 announced Zepbound would be its preferred GLP-1 drug to treat overweight or obesity in adults, mandating patients switch from other options, such as Wegovy or Saxenda.
Curex: An Alternative for Allergy and Weight Management
Curex offers comprehensive care for allergies, asthma, and eczema, including customized sublingual immunotherapy, at-home concierge allergy testing, and symptom management. While it is difficult to estimate out-of-pocket costs prior to a claim being submitted, the team will work with you to make sure your treatment is as affordable as possible. The average patient responsibility is $200/year and depends on your plan (deductibles, coinsurance, telemedicine benefit). In addition, Curex accepts HSA and FSA.
Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you.
If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide. Depending on your treatment goals, other medications such as metformin may also be considered.
Compounded Medications
Curex providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster. Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list.
These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.
Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list.