MedicaidCoverageHigh impact
25-1415 Medi-Cal Rx Coverage Changes for GLP-1 Medications
Health Net·CA · Family Medicine, Internal Medicine, Endocrinology +1 more·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Effective January 1, 2026, Medi-Cal Rx will discontinue coverage for GLP-1 medications (Wegovy, Zepbound, Saxenda) for weight loss indications, with very limited exceptions. Other GLP-1 medications will only be covered for type 2 diabetes, not weight loss, and will require Code I diagnosis restrictions.
Action Required
Before January 1, 2026: Billing team must update systems to expect denials (Reject Code 70 and 80) for GLP-1 weight loss prescriptions for Medi-Cal Rx patients. Providers must review current weight loss prescriptions and plan alternative therapies. Update prior authorization workflows to only submit requests for approved exceptions (MASH, cardiovascular disease for Wegovy; sleep apnea for Zepbound; diabetes for other GLP-1s; members under 21). All previously approved prior authorizations will expire and claims will be denied without meeting new criteria.