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25-1414 Medi-Cal Rx Coverage Changes for GLP-1 Medications

Date: 12/30/25

Action required: Review weight loss prescriptions and plan alternative therapies

Effective January 1, 2026, Medi-Cal Rx will remove coverage for Wegovy®, Zepbound® and Saxenda® for weight loss, with limited exceptions for specific medical conditions. Other GLP-1 medications will remain covered only for type 2 diabetes − not for weight loss indications.

Key changes starting January 1, 2026

  • Wegovy, Zepbound and Saxenda will be removed from the Medi-Cal Rx Contract Drugs List (CDL) for weight loss and related uses.
  • All claims for these medications will be denied with Reject Code 70 – Product/Service Not Covered, regardless of the indication.
  • Previously approved prior authorizations will expire.

Exceptions: When coverage may still apply

Prior authorization requests will only be considered for:

  • Wegovy: Noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) or cardiovascular disease
  • Zepbound: Obstructive sleep apnea

Other GLP-1 medications for diabetes only

The following GLP-1 medications remain on the CDL for type 2 diabetes (Code I diagnosis restriction), but will not be covered for weight loss:

  • Ozempic®
  • Rybelsus®
  • Mounjaro®
  • Victoza®
  • Byetta®
  • Bydureon®
  • Trulicity® (Code I diagnosis restriction is effective January 1, 2026)

Claims denials

Claims for these medications will be denied with Reject Code 80 – Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria if the Code I diagnosis is not met.

Prior authorization review

Prior authorization requests for non-weight loss indications will be reviewed based on medical necessity.

Special consideration for members under age 21

Starting January 1, 2026, prior authorization requests for weight loss indications will be considered for members under age 21 under the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

Need more information and questions?

For details, refer to the GLP-1 Coverage Considerations (PDF) document.

For questions about this change, contact CalViva Health at 888-893-1569. Behavioral health providers can call 844-966-0298.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.



Last Updated: 12/30/2025