Weight Loss GLP-1 Coverage Requirements

MIT will maintain current GLP-1 coverage for employees who take these medications for certain medical conditions, other than weight loss, such as type 2 diabetes. Employees receiving GLP-1 medications for type 2 diabetes are not required to enroll in the 9amHealth program or meet the new BMI requirements noted above. However, members can still choose to use 9amHealth at no extra cost.

If you are already taking one of these weight loss medications, a new prior authorization review will be required in 2027. Your treating physician will look at your documented BMI and any comorbidities at the time you first started receiving coverage for the medications. For example, if your initial BMI measurement was 32 or above, you will continue to be covered for these medications. If your initial BMI does not meet the new BMI criteria outlined above, your GLP-1 medication will no longer be covered.

If your BMI is 32 or higher, you can qualify for coverage. As noted above, the new prior authorization review will look at your documented BMI at the time you started receiving coverage for the medication.

If your BMI is 27 to 31, you can qualify for coverage only if you also have two comorbidities such as, asthma, COPD, coronary artery disease, heart disease, high blood pressure, high cholesterol, non-alcoholic fatty liver disease, and obstructive sleep apnea.

Wegovy® (injectable only), Zepbound®, and Saxenda® are GLP-1 medications approved by the U.S. Food and Drug Administration (FDA) for weight management.

If you met the new BMI criteria at the time you were initially approved to start the medication through a prior authorization, your coverage will continue only if you also join and participate in the 9amHealth virtual weight management program.

Any current participant taking GLP-1 medications for weight loss will need to obtain a new prior authorization the next time they refill their prescription beginning on or after January 1, 2027. Participants will also need to enroll in the 9amHealth program by February 1, 2027. Individuals who need to refill a prescription in January will not need to meet the new 9amHealth program requirements for that month.

Once you’ve enrolled in the 9amHealth program, your doctor can request a review for prior authorization for that month.

If you are enrolled in an MIT health plan and have a new prescription for a GLP-1, you will need a prior authorization submitted to Express Scripts (ESI). Additionally, you will be required to sign up for the 9amHealth program. Since there is a 30-day grace period in which to sign up, you do not have to meet the program requirements within the first 30 days.

If you do not meet the new coverage requirement and a new prior authorization is not approved, your GLP-1 medication will not be covered by your MIT health plan. However, members can still choose to use the 9amHealth program for their weight loss journey at no extra cost.

9amHealth is a virtual clinic that offers whole body care to prevent and treat obesity, type 2 diabetes, high blood pressure, and high cholesterol from the comfort of your home. Access to 9amHealth and its app is part of the prescription drug benefit at no extra cost to you. It may include custom care plans, a connected weight scale, lab tests, and expert guidance to help you live healthier every day. With 9amHealth, members have access to obesity specialists, dietitians, and pharmacists—all working together to provide personalized, expert care. Once enrolled and approved for coverage of the medication, you will receive a smart scale to use for your required weigh ins.

If you are approved for coverage for a GLP-1 weight loss medication, and are enrolled in an MIT health plan, you are required to use 9amHealth to receive your medication. If you are not approved for coverage, you are not required to use the program.

To enroll in 9amHealth, register or log in to esrx.com/healthsolutions on or after January 1, 2027, to access the 9amHealth registration link.

If you have trouble enrolling, please reach out to 9amHealth at support@join9am.com or (202) 932-9958.

Once you have successfully enrolled in 9amHealth, ask your doctor to visit the EviCore by Evernorth® portal at www.evicore.com, or call Express Scripts (ESI) at 800-417-1764 to arrange for a prior authorization review. If your doctor does not complete this step you will be responsible for the full cost of your medication.

You will need to do the following:

• Complete a medical questionnaire.
• Connect with 9amHealth’s team of medical experts. You will receive a welcome message explaining everything you need to know about the program. Engagement plans are based on an individual’s needs and may vary from participant to participant.
• Begin the path to a healthy weight. Once you engage with 9amHealth, they will send you a scale and directions on how often to weigh yourself.
• Stay engaged. In addition to weighing yourself at least four times per 30-day rolling period you must complete at least four activities through the 9amHealth program.
• Continue getting access to medications. 9amHealth will send your engagement information to Express Scripts (ESI) to ensure you continue to receive your medication.

No. When you enroll, you can choose between two participation options:

• The Coaching Journey allows you to continue working with your existing health care providers, including your current GLP-1 medication prescriber. You get access to one-on-one virtual health coaching to support sustainable lifestyle changes; educational models and resources on nutrition, physical activity, and metabolic health; and registered dietitian support and meal-planning tools.
• The All-in-One Concierge Care plan offers personalized and comprehensive care and requires that your GLP-1 prescription be managed by 9amHealth providers. It includes everything in the Coaching Journey plus virtual visits with board-certified providers specializing in weight care, type 2 diabetes, and cardiometabolic conditions; personalized care plans including medication management, lab orders, and help navigating insurance approvals.

Whether you choose the Coaching Journey or All-in-One Concierge, you will still need to complete the four weigh ins and four activities in the 9amHealth app/website per 30-day rolling period.

You can download the 9amHealth app directly from the Apple App Store for iOS devices or the Google Play Store for Android devices.

If you selected the All-in-One Concierge Care plan, you elected to have 9amHealth as your new prescriber. This change triggers additional continuation-therapy questions, such as capturing prescription information to verify you are taking a GLP-1, and to confirm the current dosage and prescribing provider. They do not receive claim information for MIT members; therefore, they ask for this information as part of your onboarding.

Once shipped, scales typically arrive within 3–5 business days. Members can also manually enter their weight should the scale not arrive in time to begin the required weigh ins.

Active engagement is defined as four weigh ins and four app/website interactions per rolling 30 days. To weigh in, step on your program-provided scale to record your weight for the day.

Examples of app/website engagements include:

• Completing your profile
• Selecting your primary physician
• Reading articles in the app
• Engaging a care specialist and/or attending an introductory or care visit
• Accessing “My Plan”
• Submitting or accessing lab results
• Uploading a recent report
• Creating a personalized treatment plan
• Completing a medical review

Files are shared daily to ensure there are no delays in receiving your prescriptions.

Your privacy is extremely important. 9amHealth is HIPAA-compliant and has a Business Associate Agreement in place with Express Scripts (ESI). This means:

• Your personal health information is protected under federal privacy laws.
• Data is handled securely and confidentially, in the same way it is with Blue Cross Blue Shield of Massachusetts, Express Scripts (ESI), and other health care providers.
• Individual-level information, such as health data, weigh ins, or app/website interactions, will not be shared with MIT. Only aggregate usage information and engagement numbers will be shared.

Being able to receive a prescription for a GLP-1 weight loss medication is dependent on four things: active enrollment in an MIT health plan; meeting the new BMI requirements; engagement with 9amHealth; and an active prior authorization with Express Scripts (ESI). If you are not enrolled in 9amHealth, you will be required to enroll in and complete the engagement requirements of the program to receive your prescription.

No. There are no new weight loss requirements associated with the 9amHealth program. The weight-loss thresholds that have long been part of the prior authorization renewal process through Express Scripts (ESI) remain unchanged. Express Scripts (ESI) has always required prescribers to confirm clinical effectiveness at prior authorization renewal. Specifically, at least:

• 4% body weight loss for Saxenda®, or
• 5% body weight loss for Wegovy® (injectable only) or Zepbound®

If these thresholds are not met, coverage may be denied. This is not a change from the previous coverage requirements.

If you are traveling for an extended period of time and are unable to weigh in, call the number on the back of your Express Scripts (ESI) ID card for directions.

No. Currently, there are no limits to how long you can receive coverage for your GLP-1 weight loss medication.

If your coverage review is denied, you and your prescriber will receive a notification from Express Scripts (ESI) with information on how to file an appeal. This will include your appeal options (pre-service, post-service, and urgent) and timeline for the appeal.