See Horizon Brief Notes below on new medical necessity policy impacts GLP-1 prescriptions for non-diabetic use for weight loss
Applies to: Fully Insured Public Sector groups and certain ASO groups at the customer’s discretion
New Medical Necessity Policy Impacts GLP-1 Prescriptions for Non-Diabetic Use for Weight Loss
At Horizon, we want to help ensure our members get the prescription medicines they need, while also helping to control costs. That’s why effective January 1, 2026, there will be a new pharmacy medical necessity policy for GLP-1 medication for non-diabetic, weight loss use for members covered under fully insured Public Sector plans and some ASO plans, at the discretion of the employer.
How This Impacts Your Clients and Their Covered Employees
Starting January 1, 2026
- Any authorizations for GLP-1s prescribed for weight loss will end on December 31, 2025 for plans with a January 1, 2026 renewal date, and on June 30, 2026 for plans with a July 1, 2026 renewal date.
- Any authorizations terminating before their group’s 2026 renewal date will require recertification based on the new medical necessity policy.
- In order for the member to get a new prior authorization, their doctor must provide medical documentation that confirms the member’s health situation meets the policy’s new requirements.
- One of the requirements of the new policy is an increase in baseline BMI to be at least 35 with comorbidity* to be eligible for weight loss.
- If a member fills a prescription after their authorization ends with no new authorization on file, they will be responsible for the total cost of the GLP-1 medicine.
Impacted members and their prescribers will receive a letter notifying them of this policy change