Removal/restriction of select GLP-1 drugs from Medi-Cal Rx Contract Drugs List for weight-loss indications
Notifies that specific GLP-1 receptor agonist products will be removed from the Medi-Cal Rx Contract Drugs List (CDL) and will no longer be covered for weight loss or weight-loss indications effective January 1, 2026; describes denial codes, PA expiration, and limited clinical exceptions where prior authorization will be considered.
Wegovy, Zepbound, and Saxenda removed from Medi-Cal Rx CDL for weight-loss indications effective January 1, 2026.
Seven other GLP-1 drugs retained on CDL will no longer be eligible for coverage for weight loss or weight-loss indications effective January 1, 2026.
Clarified that PA requests for weight-loss indications for members <21 will be reviewed under EPSDT.
Summary of changes and effective date
Background: The bulletin notifies that specific GLP-1 receptor agonist products on the Medi‑Cal Rx Contract Drugs List (CDL) will be removed or have coverage restricted for weight‑loss indications effective January 1, 2026.
Material changes: Wegovy, Zepbound, and Saxenda will be removed from the CDL and will no longer be eligible for coverage for weight loss or weight‑loss indications. Claims for these three drugs will deny with Reject Code 70 — Product/Service Not Covered — regardless of indication, and previously approved prior authorizations will expire as of January 1, 2026.
Other GLP‑1 agents (including Ozempic, Rybelsus, Mounjaro, Victoza, Byetta, Bydureon, and Trulicity) will remain on the CDL with a Code I diagnosis restriction of type 2 diabetes and will no longer be eligible for coverage for weight loss or weight‑loss indications; claims for these drugs will deny with Reject Code 80 when the Code I restriction is not met, and PA requests for non‑weight‑loss indications will be reviewed for medical necessity.
Exceptions and EPSDT: Prior authorization requests for Wegovy will be considered for noncirrhotic metabolic dysfunction‑associated steatohepatitis (MASH) or cardiovascular disease, and PA requests for Zepbound will be considered for obstructive sleep apnea (OSA). Effective January 1, 2026, PA requests for weight‑loss indications for members younger than 21 years will be reviewed under EPSDT.
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