Medi-Cal Pharmacy (Rx) – Wegovy Coverage Update
| Date: | May 13, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Practitioners, Facilities, and Hospitals |
| Type: | Informational/Educational |
| Subject: | Medi-Cal Pharmacy (Rx) – Wegovy Coverage Update |
| Business: | Medi-Cal Managed Care |
Effective April 1, 2026, Medi-Cal Rx will not require a prior authorization (PA) for Wegovy, a GLP-1 drug, if prescribed for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH).
- Prescribers must provide the diagnosis code with the prescription to the pharmacy.
- Pharmacies must submit with the following ICD-10-CM for a successful claim: 0 and/or K75.8. If incorrectly submitted or submission without the diagnosis code, the claim will result with a denial of: Reject Code 80 – Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria. Note: previously approved PAs will not override the rejection.
- For other indications of treatment or diagnosis, a PA must be submitted to Medi-Cal Rx. Note: Wegovy is not covered for weight loss or weight-loss indications.
For additional information, please visit the following Medi-Cal Rx weblink: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2026/04_A_Changes_GLP-1_Drug_Coverage_Wegovy.pdf
Effective April 27, 2026, due to stakeholder feedback and to support continuing care for impacted members, the following has been implemented by Medi-Cal Rx:
- For members younger than 21 years of age, a temporary override for Wegovy will be accepted by Medi-Cal Rx until September 30, 2026. All claims with a date of service after this date will require a PA or if the covered diagnosis applies, the pharmacy must submit the approved ICD-10-CM code for a successful claim. Requirements for the override of Reject Code 80 are:
- Date of service on or after April 1, 2026
- A prior paid claim with a date of service on or after January 1, 2026
- For members 21 years of age and older, previously and currently approved PAs for Wegovy submitted on or after January 1, 2026, through March 31, 2026, will receive paid claims during the approved period for that PA.
- For all other indications of use, a PA submission will be required.
- Exception: members with the diagnosis for noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)
- Exclusion: member use for weight loss or weight-loss indications
For additional information, please visit the following Medi-Cal Rx weblink:
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
