Wegovy (semaglutide) — Medi‑Cal Rx Code I diagnosis restriction and temporary continuation guidance
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Updates to Medi‑Cal Rx processing and prior authorization requirements for Wegovy (semaglutide) claims, describing temporary overrides for patients under 21 and honoring certain prior authorizations for adults; intended for pharmacy providers and prescribers serving Health Plan of San Joaquin members.
A new Code I diagnosis restriction for Wegovy requires an appropriate ICD-10-CM diagnosis for coverage and causes Reject Code 80 to block previously approved PAs.
Temporary continuation of therapy override for Reject Code 80 for members younger than 21 through September 30, 2026, when specific conditions are met.
For members 21 and older, PAs submitted Jan 1–Mar 31, 2026 will be honored through the previously approved authorization period.
Coverage Criteria
Temporary continuation (members <21)
Temporary continuation of therapy override for Reject Code 80 applies when ALL of the following are met:
Override active through September 30, 2026.
Override active through September 30, 2026.
Override active through September 30, 2026.
Honored prior authorizations (members 61)
For members 21 years of age and older:
No further action required for those PAs.
Claims for Wegovy with a date of service on or after October 1, 2026 require either an active, approved prior authorization (PA) or submission of an appropriate ICD-10-CM diagnosis code(s) for noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH). Claims that do not meet the Code I diagnosis restriction will be blocked by Reject Code 80 unless an active PA is on file.
Coding and Claims Requirements
| ICD-10-CM | appropriate diagnosis code(s) for noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) required for coverage when indicated |
| Reject Code 80 | Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria |
Provider Actions and Next Steps
Prior authorization required when diagnosis does not meet Code I
New prior authorization requests to Medi‑Cal Rx are required for Wegovy coverage when the claim does not meet the Code I diagnosis restriction; previously approved PAs do not override Reject Code 80. Providers should begin submitting new PA requests to Medi‑Cal Rx for coverage consideration prior to October 1, 2026 for indications that do not meet the Code I diagnosis restriction.
- Previously approved PAs do not override Reject Code 80; a new PA is required when the submitted diagnosis does not meet the Code I restriction.
- Submit new PA requests to Medi‑Cal Rx prior to October 1, 2026 for indications outside the Code I diagnosis restriction.
When a claim denies for members ≥21 — submit a PA
If a Wegovy claim for a member aged 21 or older denies, providers must submit a prior authorization request to Medi‑Cal Rx for coverage consideration.
- For members 21 and older, approved PAs submitted Jan 1–Mar 31, 2026 will be honored through the authorization period; other denials require PA submission.
Documentation and resubmission steps for members <21 (temporary override)
Claims for members younger than 21 may qualify for a temporary continuation override of Reject Code 80 if all conditions are met: the Wegovy claim has a date of service on or after April 1, 2026 and there is a paid claim in the member's history with a date of service on or after January 1, 2026; providers should resubmit previously denied Wegovy claims with DOS on/after April 1, 2026 to Medi‑Cal Rx to capture the override. Note the override is active only through September 30, 2026; claims with DOS on or after October 1, 2026 require an active, approved PA or an appropriate ICD-10-CM diagnosis code for noncirrhotic MASH.
- Resubmit previously denied Wegovy claims for members <21 with DOS on or after April 1, 2026 to Medi‑Cal Rx to determine override eligibility.
- Temporary override requires a paid claim in the member's history with DOS on or after January 1, 2026.
- Override expires September 30, 2026; DOS on/after October 1, 2026 require an approved PA or appropriate ICD-10-CM diagnosis code(s).
Reject Code 80 will block Wegovy claims when diagnosis doesn't meet Code I
Reject Code 80 — “Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria” — will block Wegovy claims when the submitted diagnosis does not meet the new Code I restriction; previously approved PAs do not override this reject.
- If Reject Code 80 is returned, submit a new PA to Medi‑Cal Rx when the diagnosis does not meet the Code I restriction (unless the claim qualifies for the temporary override for members <21).
- Providers should refer to the alert How to Address Reject Code 80 for next steps when a claim denies.
Definitions
Background
This policy reflects operational changes to Medi‑Cal Rx processing for Wegovy tied to a new Code I diagnosis restriction. To support continuity of care, Medi‑Cal Rx implemented a temporary continuation-of-therapy override of Reject Code 80 for members younger than 21; that override is active for qualifying claims with DOS on or after April 1, 2026 and remains in effect through September 30, 2026. The override requires that a paid claim exists in the member’s history with DOS on or after January 1, 2026. For members 21 and older, prior authorizations submitted between January 1, 2026 and March 31, 2026 will be honored through their previously approved authorization period; other claims that do not meet the Code I restriction will require submission of a new PA for coverage consideration.
Initial Therapy Criteria
New PA requests
Provider submission requirements
Resubmit previously denied Wegovy claims for members <21 with DOS on or after April 1, 2026 to capture temporary override.
Continuation Criteria
Temporary continuation override
Temporary continuation for younger members
Override active through September 30, 2026; resubmission of previously denied claims is recommended.
Step Therapy
| Step | Action |
|---|---|
| 1 | If a Wegovy claim denies for a member 21 years of age or older, submit a prior authorization (PA) request to Medi‑Cal Rx for coverage consideration. |
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