Medicaid coverage
Does California Medi-Cal (Medi-Cal Rx) cover Rybelsus?
Rybelsus (semaglutide (oral)) for type 2 diabetes — the California Medi-Cal (Medi-Cal Rx) prior-authorization rule, source-cited.
California Medi-Cal (Medi-Cal Rx) Rybelsus PA criteria
Seven GLP-1 drugs remain on the Medi-Cal Rx CDL for type 2 diabetes: Ozempic, Rybelsus, Mounjaro, Victoza, Byetta, Bydureon, Trulicity.
They carry a 'Code I' type 2 diabetes diagnosis restriction - claims must include a clinically appropriate T2DM ICD-10 code; claims not meeting the Code I restriction deny with Reject Code 80.
PA requests for non-weight-loss indications are reviewed for coverage consideration based on medical necessity.
No specific metformin step-therapy or first-line requirement is published; utilization control is governed by the CDL Code I diagnosis restriction itself.
Source: DHCS Medi-Cal Rx 'GLP-1 Coverage Considerations' bulletin (administered by Prime Therapeutics State Government Solutions). View cited GLP-1 policy reference →
Frequently asked
- Does California Medi-Cal (Medi-Cal Rx) cover Rybelsus for type 2 diabetes?
- Covered with prior authorization. Seven GLP-1 drugs remain on the Medi-Cal Rx CDL for type 2 diabetes: Ozempic, Rybelsus, Mounjaro, Victoza, Byetta, Bydureon, Trulicity. See the full source-cited criteria above. Per DHCS Medi-Cal Rx 'GLP-1 Coverage Considerations' bulletin (administered by Prime Therapeutics State Government Solutions), as of 2026 (bulletin Dec 12 2025, last updated Apr 6 2026; CDL removals eff. 1/1/2026; Wegovy MASH eff. 4/1/2026) — confirm the member's current plan policy.
d3rx does not hold plan-specific pharmacy formularies or PBM prior-auth grids, so it cannot confirm a particular plan's GLP-1 coverage, tier, or PA criteria. The guidance below is the general, source-cited rule; confirm the specific plan's pharmacy formulary / PA policy for a binding answer.
Check Rybelsus for another payer — or draft the PA
Run Rybelsus + any payer in the GLP-1 PA lookup, or have Ask D3 draft a California Medi-Cal (Medi-Cal Rx)-ready prior-authorization request with the right criteria and codes — free, no signup.