25-1412 Coverage Alert: Required Action for Weight Loss Medication Changes

Date: 12/29/25

New eligibility rules and benefit verification requirements starting January 1, 2026

Beginning January 1, 2026, Health Net will implement updated coverage requirements for weight loss medications. These changes affect benefit criteria, eligibility rules and weight loss program compliance for members.

What’s changing?

New coverage criteria and eligibility requirements will apply to weight loss medications. See the table below for full details on benefit changes, body mass index (BMI) thresholds and weight loss program requirements by line of business.

Action required: Steps for participating physician groups (PPGs)

PPGs with risk for self-injectable medications must take the following actions to ensure compliance and continuity of care.

1 Review updated benefit and eligibility criteria
Understand new BMI thresholds and program requirements, effective January 1, 2026. The new clinical criteria and Pharmacy Prior Authorization Guidelines will be posted on January 1,2026.

2 Check if the member’s plan is Individual & Family Plans (IFP), Large Group or Small Group
Review the Schedule of Benefits on the secure provider portal; this information will show at the top.

3 Verify pharmacy coverage details
For questions or to confirm benefits, contact Provider Services.

4 Maintain member compliance
Ensure members prescribed weight loss medications remain enrolled in Health Net-approved or physician-recommended lifestyle modification programs to maintain ongoing coverage.

5 Submit correct encounter data
Encounter data submissions must include accurate member-paid cost-share amounts, including copayment, coinsurance and deductibles, applicable to the member’s benefit.

Is prior authorization required?

Yes – physicians affiliated with a PPG must follow the PPG’s prior authorization requirements and Health Net’s Pharmacy Prior Authorization Guidelines. The revised guidelines will be posted on January 1,2026, at Pharmacy Prior Authorization Guidelines.

Weight loss medication coverage by line of business, effective January 1, 2026

Line of business	Weight loss medication benefit changes	Current prescriptions	How to verify benefits
Individual & Family Plans (IFP) HMO and PPO (Ambetter)	New prescriptions beginning January 1, 2026: Coverage for weight loss medications will be limited to members with a BMI ≥ 40 (severe obesity).	Current Health Net members already prescribed GLP-1s or other weight loss medications for obesity (BMI ≥ 30 or BMI ≥ 27 kg/m2 with at least one comorbid condition) will continue to receive coverage. Coverage is dependent on the: Prescribers must continue to prescribe the medication and request prior authorization for medical necessity. If a member discontinues the medication for 60 days or more, they will be subject to the new BMI requirements upon prescription renewal. Member’s continued enrollment in a Health Net-approved or physician-recommended lifestyle modification weight loss program. New Health Net members will need to meet the current eligibility criteria.	The member’s ID card indicates the line of business.   PPGs unsure of the member’s specific pharmacy benefits should call Provider Services using the phone number on the back of the member’s ID card.
Large Group HMO and PPO and custom groups (Full HMO, ExcelCare, Smart Care, Salud HMO y Mas, CanopyCare, Blue & Gold HMO, Elect Open Access, Excel Care Elect Open Access, PPO)	New prescriptions beginning January 1, 2026: Coverage for weight loss medications will be limited to members with a BMI ≥ 40 (severe obesity). Buy-up option starting January 1, 2026: Large HMO, Elect Open Access and PPO groups may elect a buy-up option for expanded coverage of weight loss medications for members with BMI ≥ 30 or BMI ≥ 27 kg/m2 with at least one comorbid condition. This benefit buy-up must be verified with Provider Services.		PPGs are required to call Provider Services to verify pharmacy benefit. Refer to the phone number on the back of the member’s ID card.
Small Group HMO and PPO (Full HMO, SmartCare, Salud HMO y Mas, WholeCare, PPO)	No benefit changes: Standard eligibility for weight loss medications remains unchanged—BMI ≥ 30 or BMI ≥ 27 kg/m2 with at least one comorbid condition.	Not applicable	PPGs unsure of the member’s specific pharmacy benefits should call the Provider Services phone number on the back of the member’s ID card.

 

Need help?

For more details about these changes, refer to Provider Update 25-1150, Weight Loss Medications Coverage Criteria – Effective January 1, 2026, distributed on October 24, 2025. Access the online version of this update in the Provider Library.
 

This information applies to Participating Physician Groups (PPGs).