25-1150 Weight Loss Medications Coverage Criteria - Effective January 1, 2026
Date: 10/24/25
New requirements and eligibility guidelines apply to members on select Health Net plans
Starting January 1, 2026, Health Net is updating its coverage criteria for weight loss medications. These changes may affect treatment planning and prescribing decisions. For members with BMI between 30 and 40, coverage for weight loss medication will depend on their plan benefits—please verify coverage before prescribing.
Impacted medical plans
This change applies to members enrolled in the following Health Net plans:
- Large group employer plans (HMO/POS)
- Large group PPO employer plans
- Individual and Family Plans (IFP) (Ambetter HMO/PPO)
Note: this does not impact small group plans. Participating physician groups (PPGs) may contact Provider Services to confirm pharmacy benefits.
What you need to know
- New requirements for weight loss medications for members with a BMI of 30 or 40.
For new prescriptions, coverage for weight loss medication for members with a BMI >30 or >40 will depend on their plan benefits. - Members with Class III severe obesity (BMI ≥ 40) continue to be eligible for coverage with prior authorization (PA) and with enrollment in a Health Net-approved weight loss program.
- Continued coverage for existing prescriptions
Members currently prescribed GLP-1s or other weight loss medications for obesity (BMI ≥ 30) will continue to be covered, provided their primary care provider maintains the prescription for obesity treatment and enrollment in a Health Net-approved weight loss program.
Steps to verify coverage before prescribing
1 Confirm the member’s pharmacy benefit
- Call Provider Services, as applicable:
- Employer Group: 800-641-7761
- IFP PPO: 844-463-8188
- IFP HMO: 888-926-2164
2 Verify enrollment in a weight loss program
Members must be enrolled in a prescriber-recommended or Health Net-approved program such as Weight Watchers. The program must include:
- A reduced-calorie diet
- Increased physical activity
- Behavioral modifications
3 Request prior authorization (PA)
- PA is required for coverage. Access the PA requirements via:
- Provider Library > select appropriate line of business > Click Prior Authorization Requirements (on the left side), or
- Directly at Prior Authorizations > select the Commercial – California Prior Authorization List.
- Physicians affiliated with a PPG must follow the PPG’s prior authorization requirements.
Covered weight loss medications
The following weight loss medications are covered, subject to PA and enrollment in an approved weight loss program:
Injectables | Oral |
|---|---|
Wegovy® | Phentermine |
Zepbound® | Phentermine-Topiramate (Qsymia®) |
Liraglutide (Saxenda®) | Contrave® |
| Orlistat (Xenical®) |
Need help?
If you have questions regarding the information contained in this update, contact us via:
- Phone: call Provider Services, as applicable at:
- Employer Group: 800-641-7761
- IFP PPO: 844-463-8188
- IFP HMO: 888-926-2164
- Portal: visit the Health Net provider portal
This information applies to Physicians and Participating Physician Groups (PPGs).