CommercialPrior AuthMedium impact
25-1150 Weight Loss Medications Coverage Criteria - Effective January 1, 2026
Health Net·CA · Family Medicine, Internal Medicine, Endocrinology +1 more·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Health Net is updating weight loss medication coverage criteria effective January 1, 2026, requiring prior authorization and enrollment in approved weight loss programs for members with BMI 30-40, while maintaining coverage for BMI ≥40. The changes apply to large group employer plans, individual/family plans, but exclude small group plans.
Action Required
Before January 1, 2026: Billing team must update prior authorization workflows for weight loss medications (Wegovy, Zepbound, Saxenda, Qsymia, Contrave, Xenical, Phentermine, Orlistat). Providers must verify patient pharmacy benefits by calling Health Net Provider Services before prescribing, confirm patient enrollment in approved weight loss programs, and obtain prior authorization for all covered weight loss medications. Front desk staff should update encounter forms to remind providers of these requirements.