We will cover GLP-1 medications only for type 2 diabetes starting on January 1, 2026 as employers renew their benefits.
GLP-1 medications approved by the U.S. Food and Drug Administration for obesity1 will be excluded from our pharmacy benefit. This means there will be no exceptions for coverage for GLP-1s for weight loss, unless the member’s employer has chosen to cover them. We’re reaching out to employers with 100 or more members to give them the option to purchase a rider to continue coverage of GLP-1s for weight loss. We have not yet notified members of this change in coverage because employers are making their decisions.
Below, we provide an overview of this change and why we’re making it. More details will be available later this year.
We believe that obesity is a disease and that these medications have great promise. While we understand their clinical benefits, they are incredibly expensive.
We are doing our best to balance providing access to the medications for those who truly need them while also being responsive to our customers who are struggling with the drugs’ soaring costs.
If we stay on the current trajectory, we forecast that we’ll spend close to a billion dollars on just these medications in 2026—which will mean significantly higher premiums for everyone—whether they use these medications or not. And several studies and simulations suggest that any future health savings will still be dwarfed by the cost of the drugs at current prices.
Members in the following health plans using a GLP-1 for any condition other than type 2 diabetes:
- Commercial members who have prescription drug coverage with us through the:
- Blue Cross Blue Shield of Massachusetts formulary
- Standard Control with Advanced Control Specialty Formulary
- Group Medex®' members with a 3-tier pharmacy benefit
- Members with our pharmacy coverage whose employer has purchased a rider to continue coverage (for GLP-1s used for obesity2) when they renew their health plan benefits throughout 2026.
- Members prescribed a GLP-1 for type 2 diabetes that’s been authorized for coverage by our Pharmacy Operations area. We describe authorization requirements in Glucagon-like Peptide-1 (GLP-1) Receptor Agonists and Related Drugs for the Treatment of Type 2 Diabetes pharmacy medical policy 056.
- Medicare Advantage plan members. (CMS currently does not allow coverage of GLP-1s for weight loss for Medicare Part D prescription drug plans).
Since we’re in the process of talking to employers about their coverage, more details will be available later this year about benefit verification and the authorization process for members who will continue to have coverage.
Throughout the year, we’ll continue to share more information on this change, including support options for members to continue with their weight loss journeys.
If you have questions about this change, contact your network representative. If you have a question about a current medication authorization, you may call Pharmacy Operations at 1-800-366-7778.
1. Or any other clinical condition, such as type 2 diabetes, as outlined on our formulary or in any applicable medical policy.
2. Or any other clinical condition as outlined on our formulary or in any applicable medical policy.
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