What does this change mean for me?

• If you take GLP-1 to treat diabetes, there is no change in coverage for you.
• If you take GLP-1 for weight loss (Saxenda, Wegovy or Zepbound), the change in coverage will go into effect on January 1, 2026 or when your plan renews in 2026 based on your employer’s group size. If you are a direct pay member or part of a small employer group with 50 or fewer employees, the change is effective as of January 1.
• If your company is a large group with less than 100 actively enrolled Health New England subscribers, the change goes into effect on your plan renewal date in 2026. (Please check with your HR department if you have questions on your group size.)
• If your company is a large group with more than 100 actively enrolled subscribers, your employer has the option to continue coverage for an additional cost upon plan renewal. If they decide to discontinue, the change will go into effect when your plan renews.

Which weight loss injections are affected by this change?

On the Health New England formulary, the following GLP-1 injections will no longer be covered for weight loss in 2026:

• Saxenda
• Wegovy
• Zepbound

If my provider is prescribing a certain weight loss drug, why won’t Health New England cover it?

Health New England network providers will be notified of this change in coverage well in advance of the effective date so they can work with you on alternatives. We are committed to providing our members access to high-quality effective care while managing health care costs for all. Our pharmacy management programs are designed to ensure members get medications that are appropriate and clinically proven to have effective outcomes.

What are the alternatives Health New England will cover if the medication being prescribed is not covered?

Health New England covers the following oral formulary alternatives:

Are there any weight loss drugs covered by Health New England (other than injections) that are strictly for weight loss (without any other diagnosis)?

• Contrave and Qsymia are both FDA-approved for chronic weight management
• Phentermine is FDA-approved for short-term weight management

What other weight-loss options do I have coverage for?

Health New England offers a variety of options to support weight-loss including:

• Nutrition therapy through Virta Health for proven weight loss and diabetes reversal
• Coverage for visits with a nutritionist
• Reimbursements for fitness center fees, gym memberships, wellness classes, weight-management programs and more
• Bariatric surgery coverage for members with prior authorization
• Health coaching and education through our Healthy Directions program

Will I receive a notification about this change?

Yes, Health New England will mail out letters to affected members in late September about this change. 

Which weight loss injections are affected by this change?

The following GLP-1 injections will no longer be covered for weight loss in 2026:

• Saxenda®
• Wegovy™
• Zepbound™

Can I request an exception or appeal to have my patient covered?

No, we are not making exceptions and coverage cannot be appealed because these drugs will be an exclusion to the member’s coverage and not part of their covered benefits. We will only cover GLP-1s for weight loss if the member’s employer purchases a rider to continue coverage.

My patient has an approved authorization beyond their renewal date. Will they have a grace period?

No, their authorization will expire upon their plan’s renewal date. For example, if the member has an authorization in place until March 1, 2026, and their plan renews on January 1, 2026, their authorization will expire on January 1, 2026.

When will my patients experience this change?

It depends on when their health plan benefits renew. For many of our members, this change will happen on January 1, 2026.

What will happen when a member still has coverage through a rider?

Members who will still have coverage will have to meet the clinical criteria and obtain prior authorization for the medication. 

What do employers need to do to request the GLP-1 rider coverage?

Employers should work with their brokers on their coverage needs. Employers with 100 or more actively enrolled subscribers can request a rider to their plan for GLP-1 coverage. Health New England will provide renewals and pricing with the GLP-1 rider upon request.

What is the pricing for the rider?

Our underwriting team will include pricing upon request in 2026 renewals for groups who are eligible. Groups with more than 100 actively enrolled subscribers are eligible for the rider option.

Will my premium go down as a result of this change?

No, your premium will not go down because of this change. We are making this change to prevent future increases in premiums and to ensure we are able to cover the ongoing costs of all our members’ care needs.

When will my affected employees be notified?

Affected members will be notified in late September before the open enrollment season.

What alternatives are there for weight loss when coverage ends?

Health New England offers a variety of options to support weight loss including:

• Nutrition therapy through Virta Health for proven weight loss and diabetes reversal
• Coverage for visits with a nutritionist
• Reimbursements for fitness center fees, gym memberships, wellness classes, weight-management programs and more
• Bariatric surgery coverage for members with prior authorization
• Health coaching and education through our Healthy Directions program