Medi-Cal — California's Medicaid program serving approximately 14.5 million beneficiaries — implemented a sweeping GLP-1 coverage change on January 1, 2026, eliminating coverage of all GLP-1 medications when prescribed solely for weight loss or weight-loss-related indications. The policy, driven by a $6.2 billion Medi-Cal budget shortfall and Governor Newsom's state budget directives, ended coverage that had been in place for weight-loss GLP-1s under the Medi-Cal Rx Contract Drugs List.
This guide maps which GLP-1 medications Medi-Cal still covers, explains the January 2026 exclusion and April 2026 update adding Wegovy for MASH, details PA criteria for remaining covered indications, and provides transition guidance for members and prescribers. It is independent information and not medical advice or reimbursement guidance for a specific patient or plan.
Quick answer
| GLP-1 Drug | Medi-Cal Coverage as of June 2026 |
|---|---|
| Ozempic (semaglutide injection) | Covered for T2D — submit with T2D ICD-10 diagnosis code. Not covered for weight loss. |
| Mounjaro (tirzepatide injection) | Covered for T2D — submit with T2D ICD-10 diagnosis code. Not covered for weight loss. |
| Trulicity (dulaglutide) | Covered for T2D — submit with T2D ICD-10 diagnosis code. Not covered for weight loss. |
| Rybelsus (semaglutide tablets) | Covered for T2D — submit with T2D ICD-10 diagnosis code. Not covered for weight loss. |
| Victoza (liraglutide) | Covered for T2D — submit with T2D ICD-10 diagnosis code. Not covered for weight loss. |
| Byetta, Bydureon | Covered for T2D — submit with T2D ICD-10 diagnosis code. Not covered for weight loss. |
| Wegovy (semaglutide) | Covered for noncirrhotic MASH (no PA needed with diagnosis code). Covered for CVD with PA. Not covered for weight loss. |
| Zepbound (tirzepatide) | Covered for OSA with PA only. Not covered for weight loss. |
| Saxenda (liraglutide 3 mg) | Not covered for any indication. Removed from Contract Drugs List. |
Key policy dates:
- May 2025: Governor Newsom proposed eliminating Medi-Cal GLP-1 weight-loss coverage, estimating $85 million in annual savings
- November 14, 2025: Medi-Cal Rx issued "GLP-1 Coverage Considerations" alert announcing the January 2026 changes
- January 1, 2026: All GLP-1 weight-loss coverage ended. Wegovy, Zepbound, and Saxonda removed from Contract Drugs List. All previously approved PAs expired December 31, 2025. Diabetes GLP-1s restricted to T2D-only diagnosis.
- April 1, 2026: Wegovy injection added back to CDL with Code 1 diagnosis restriction for noncirrhotic MASH — no PA required if correct ICD-10 codes submitted
Who this is for
- Medi-Cal fee-for-service members and their prescribers navigating the post-January 2026 GLP-1 coverage rules
- Medi-Cal managed care plan members (L.A. Care, Central California Alliance for Health, Health Plan of San Joaquin, IEHP, and others) subject to the same Medi-Cal Rx policy
- Benefit verification specialists and hub teams handling Medi-Cal pharmacy claims
- Market access teams tracking the largest state Medicaid GLP-1 policy change in the US
- California healthcare providers seeking to maintain GLP-1 access through covered non-weight-loss diagnoses
Source standard
Every fact in this guide is sourced from Medi-Cal Rx provider alerts, California Department of Health Care Services (DHCS) policy documents, Medi-Cal Rx Contract Drugs List updates, California Medical Association guidance, California Pharmacists Association bulletins, and managed care plan notices dated 2025–2026. Always verify current coverage by calling the Medi-Cal Rx Customer Service Center at 1-800-977-2273 or checking the Medi-Cal Rx portal at medi-calrx.dhcs.ca.gov.
Medi-Cal program structure and GLP-1 policy
How Medi-Cal Rx works
Medi-Cal pharmacy benefits are administered through Medi-Cal Rx, which uses Prime Therapeutics as the pharmacy benefit manager. Key structural features:
- Contract Drugs List (CDL): The formulary that determines which drugs are covered. GLP-1 policy changes are implemented through CDL updates
- Code I diagnosis restrictions: Certain drugs require a specific ICD-10 diagnosis code to be submitted with the prescription for the claim to process
- Prior authorization (PA): Required for non-formulary drugs, drugs outside diagnosis restrictions, and special clinical circumstances
- Managed care alignment: All Medi-Cal managed care plans must follow Medi-Cal Rx GLP-1 coverage policies — the exclusion applies uniformly across fee-for-service and managed care
Why the exclusion happened
Governor Newsom's May 2025 budget proposal cited several factors:
- Medi-Cal faced a $6.2 billion budget shortfall, requiring cost reductions
- GLP-1 prescription spending was a significant driver of budget overruns
- Federal law does not require states to cover weight-loss drugs in Medicaid
- California had voluntarily included GLP-1 weight-loss coverage but could no longer sustain the cost
The California Association of Health Plans supported the decision, noting it "should send a strong signal to the Legislature that they should reconsider mandating that health plans cover these costly drugs for weight loss without the proper clinical safeguards in place."
Covered GLP-1 drugs after January 1, 2026
Type 2 diabetes GLP-1s
Seven GLP-1 drugs remain on the CDL for type 2 diabetes with a Code I diagnosis restriction:
| Drug | Diagnosis Restriction | PA Required? | Claims Processing |
|---|---|---|---|
| Ozempic (semaglutide injection) | T2D only (Code I) | No, if correct ICD-10 submitted | Denies with Reject Code 80 if T2D code not submitted |
| Mounjaro (tirzepatide) | T2D only (Code I) | No, if correct ICD-10 submitted | Denies with Reject Code 80 if T2D code not submitted |
| Trulicity (dulaglutide) | T2D only (Code I), effective Jan 1, 2026 | No, if correct ICD-10 submitted | Denies with Reject Code 80 if T2D code not submitted |
| Rybelsus (semaglutide tablets) | T2D only (Code I) | No, if correct ICD-10 submitted | Denies with Reject Code 80 if T2D code not submitted |
| Victoza (liraglutide) | T2D only (Code I) | No, if correct ICD-10 submitted | Denies with Reject Code 80 if T2D code not submitted |
| Byetta (exenatide) | T2D only (Code I) | No, if correct ICD-10 submitted | Denies with Reject Code 80 if T2D code not submitted |
| Bydureon (exenatide ER) | T2D only (Code I) | No, if correct ICD-10 submitted | Denies with Reject Code 80 if T2D code not submitted |
Prescriber action: Submit the prescription with an appropriate T2D ICD-10-CM diagnosis code from the Medi-Cal Rx Diagnosis Crosswalk. Claims without the diagnosis code will deny with Reject Code 80 — "Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria."
Wegovy for non-weight-loss indications
Wegovy has two covered non-weight-loss pathways:
1. Noncirrhotic MASH (no PA required)
Effective April 1, 2026, Wegovy injection was added to the CDL with a Code 1 diagnosis restriction for noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH).
- No PA required if appropriate ICD-10-CM diagnosis codes from the Medi-Cal Rx Diagnosis Crosswalk are submitted with the prescription
- This is a significant update — it means MASH patients can access Wegovy without prior authorization delays
2. Cardiovascular disease (PA required)
Medi-Cal Rx reviews PA requests for Wegovy when used for cardiovascular disease on a case-by-case basis to establish medical necessity.
- PA must document the CVD indication and supporting clinical evidence
- Reviewed individually — not guaranteed approval
Zepbound for obstructive sleep apnea (PA required)
Zepbound is covered only for obstructive sleep apnea (OSA) with PA.
- PA must document OSA diagnosis and clinical necessity
- Reviewed on a case-by-case basis
Excluded drugs and claim denial codes
Wegovy, Zepbound, and Saxenda for weight loss
Claims submitted for these three drugs on or after January 1, 2026, will deny with:
- Reject Code 70: "Product/Service Not Covered"
- Supplemental message: "GLP-1s for weight loss are not covered. For EPSDT or other FDA approved indications, submit a PA establishing medical necessity. Not a Medi-Cal Rx covered pharmacy benefit."
Diabetes GLP-1s submitted without T2D code
Claims for Ozempic, Mounjaro, Trulicity, Rybelsus, Victoza, Byetta, or Bydureon submitted without a T2D diagnosis code will deny with:
- Reject Code 80: "Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria"
EPSDT: Members under 21
Under the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, Medi-Cal must cover medically necessary services for members under age 21, including GLP-1s for weight loss:
- PA requests for GLP-1 weight-loss drugs for members under 21 are reviewed for medical necessity
- Coverage is not automatic — the PA must establish medical necessity
- This applies to both fee-for-service and managed care members
Member rights: State Hearing
Medi-Cal members who receive a Notice of Action (NOA) denying GLP-1 coverage have the right to a State Hearing:
- Timeline: 90 days from the date of the NOA to submit a written request to the California Department of Social Services (CDSS)
- Aid Paid Pending: Members who were taking GLP-1 drugs on or before January 1, 2026, who request a State Hearing within 10 days of receiving an NOA may continue to receive GLP-1 drugs pending the hearing decision
- Continuation limits: Coverage continues until the earlier of: (a) the end of the current PA period, (b) the date of the State Hearing decision, or (c) the date the hearing is withdrawn
State Hearing contact information:
- State Hearings Division, P.O. Box 944243, MS 21-37, Sacramento, CA 94244-2430
- Toll Free: 1-800-743-8525 or 1-855-795-0634
- Fax: 1-833-281-0905
Transition guidance for prescribers
Members on Wegovy or Zepbound for weight loss
- Check for covered diagnoses: Screen for T2D, prediabetes, CVD, MASH, or OSA
- If T2D found: Switch to a diabetic GLP-1 (Ozempic, Mounjaro, Trulicity) and submit with T2D ICD-10 code
- If MASH found: Submit Wegovy prescription with MASH diagnosis code — no PA needed per April 2026 update
- If CVD found: Submit PA for Wegovy with CVD documentation
- If OSA found: Submit PA for Zepbound with OSA documentation
- If no covered indication: Discuss alternative weight-management options including lifestyle programs, diet changes, and exercise counseling
Members on Ozempic or Mounjaro for weight loss (off-label)
- If T2D is documented: Ensure prescriptions are submitted with T2D ICD-10 code — should process without PA
- If no T2D: The prescription will deny. Discuss diabetes screening and alternative approaches
Members under 21
- Submit PA with EPSDT medical necessity documentation
- Include clinical rationale for GLP-1 therapy
- Document BMI, comorbidities, and prior treatment history
Medi-Cal managed care plan implementation
All Medi-Cal managed care plans have implemented the GLP-1 weight-loss exclusion. Key plans and their communications:
| Plan | Communication | Key Details |
|---|---|---|
| L.A. Care Health Plan | Formulary update January 2026 | GLP-1s covered only for FDA-approved non-weight-loss indications with correct diagnosis and PA |
| Central California Alliance for Health | Provider news December 26, 2025 | Wegovy/Zepbound/Saxenda removed from CDL; T2D GLP-1s require diagnosis code |
| Health Plan of San Joaquin | Provider notice December 8, 2025 | 30-day countdown alert with full claim denial code details |
| IEHP | Provider notice December 15, 2025 | GLP-1 coverage considerations with transition guidance |
| Multiple plans | Member FAQ documents | Right to State Hearing; EPSDT under-21 access |
National context
California was one of four states that eliminated Medicaid GLP-1 weight-loss coverage between October 2025 and January 2026, along with New Hampshire, Pennsylvania, and South Carolina. KFF data from January 2026 shows only 13 state Medicaid programs still covering GLP-1s for obesity treatment under fee-for-service, down from 16 in October 2025.
North Carolina also eliminated GLP-1 coverage in October 2025 due to a budget stalemate, though coverage was later restored when the budget was resolved.
What to monitor next
- Wegovy for CVD PA criteria: Medi-Cal Rx may issue specific PA forms and clinical criteria for Wegovy CVD coverage beyond the current case-by-case review
- Zepbound OSA PA criteria: Specific documentation requirements for OSA PA requests may be formalized
- Budget restoration: If California's fiscal position improves, the legislature could restore GLP-1 weight-loss coverage
- New FDA indications: Future approvals for Wegovy or Zepbound for kidney disease, NASH, or other conditions could expand covered indications
- Medicare GLP-1 Bridge demonstration: If Medicare expands GLP-1 coverage starting July 2026, California may face pressure to maintain access for dual-eligible members
- Generic GLP-1 entry: When generic semaglutide or tirzepatide becomes available, the cost calculus could shift
Sources
- CMS. "Medicaid Drug Coverage and Rebate Programs." cms.gov. https://www.cms.gov/medicaid/prescription-drugs
- FDA. "FDA Approves New Indication for Wegovy (semaglutide) Injection to Reduce Risk of Major Cardiovascular Events." fda.gov, March 8, 2024. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda-approves-new-indication-wegovy-semaglutide-injection-reduce-risk-major-cardiovascular-events
- Medi-Cal Rx. "GLP-1 Coverage Considerations." medi-calrx.dhcs.ca.gov, December 12, 2025. https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2025/12_A_GLP-1_Coverage_Considerations.pdf
- Medi-Cal Rx. "Changes to GLP-1 Drug Coverage – Effective January 1, 2026." Member FAQ. https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/member/GLP1_Changes.pdf
- Medi-Cal Rx. "State Budget Policy Updates – Frequently Asked Questions." medi-calrx.dhcs.ca.gov. https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/faq/State_Budget_Policy_Updates_FAQ.pdf
- Medi-Cal Rx. "GLP-1 Drugs – Members' Frequently Asked Questions." Version 4.0, December 29, 2025. https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/faq/Members_State_Budget_Policy_Updates_FAQ.pdf
- California Pharmacists Association. "Updates to the Medi-Cal Rx Contract Drugs List regarding GLP-1s." cpha.com, April 2026. https://cpha.com/wp-content/uploads/2026/04/Updates-to-the-Medi-Cal-Rx-Contract-Drugs-List-regarding-GLP-1s.pdf
- California Medical Association. "GLP-1 medications for weight loss will no longer be covered by Medi-Cal." cmadocs.org. https://www.cmadocs.org/newsroom/news/view/ArticleId/51074/GLP-1-medications-for-weight-loss-will-no-longer-be-covered-by-Medi-Cal
- CalMatters. "Medi-Cal coverage of weight loss drugs on chopping block under governor's proposal." calmatters.org, May 14, 2025. https://calmatters.org/health/2025/05/medi-cal-coverage-weight-loss-drugs-newsom-california
- L.A. Care Health Plan. "Update to GLP-1 Medication Coverage for Medi-Cal Members." lacare.org, 2026. https://www.lacare.org/providers/pharmacy-services/medication-adherence/list-covered-drugs
- Central California Alliance for Health. "GLP-1 drug changes effective starting January." thealliance.health, December 26, 2025. https://thealliance.health/glp-1-drug-changes-effective-starting-january
- KFF. "Medicaid Coverage of and Spending on GLP-1s." kff.org, 2026. https://www.kff.org/medicaid/medicaid-coverage-of-and-spending-on-glp-1s
