CommercialPrior AuthHigh impact
25-1412 Coverage Alert: Required Action for Weight Loss Medication Changes
Health Net·CA · Family Medicine, Internal Medicine, Endocrinology +2 more·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Starting January 1, 2026, Health Net will restrict weight loss medication coverage to members with BMI ≥ 40 for Individual & Family Plans and Large Group plans, while Small Group plans maintain current BMI ≥ 30 criteria. All weight loss medications will require prior authorization and members must remain enrolled in approved lifestyle modification programs.
Action Required
By January 1, 2026: Billing team must verify patient BMI requirements before prescribing weight loss medications - BMI ≥ 40 for Individual & Family Plans and Large Group plans, BMI ≥ 30 for Small Group plans. All providers must obtain prior authorization for weight loss medications using updated Pharmacy Prior Authorization Guidelines (posted Jan 1, 2026). Verify member's plan type (IFP, Large Group, Small Group) through secure provider portal and call Provider Services to confirm pharmacy benefits. Ensure encounter data includes accurate member cost-share amounts. Claims will be denied without proper prior authorization.