MedicaidCoverageHigh impact
25-1413 Medi-Cal Rx Coverage Changes for GLP-1 Medications
Health Net·CA · Endocrinology, Family Medicine, Internal Medicine +1 more·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Effective January 1, 2026, Medi-Cal Rx will remove coverage for Wegovy, Zepbound, and Saxenda for weight loss indications, with very limited exceptions. Other GLP-1 medications (Ozempic, Mounjaro, etc.) will only be covered for type 2 diabetes, not weight loss, and will require specific diabetes diagnosis codes.
Action Required
Before January 1, 2026: Billing team must update prior authorization workflows to discontinue requests for Wegovy, Zepbound, and Saxenda for weight loss indications - these will be automatically denied with Reject Code 70. Update system to flag GLP-1 medications requiring Code I diagnosis restriction for diabetes only. Providers must review all current weight loss prescriptions and plan alternative therapies. Contact patients with existing prior authorizations as they will expire. Claims will be denied with Reject Code 80 if diabetes diagnosis codes are not met.