Medicaid coverage
Does California Medi-Cal (Medi-Cal Rx) cover Zepbound?
Zepbound (tirzepatide) for weight loss / obesity — the California Medi-Cal (Medi-Cal Rx) prior-authorization rule, source-cited.
California Medi-Cal (Medi-Cal Rx) Zepbound PA criteria
Weight loss is not and never has been a Medi-Cal-covered indication.
Effective 1/1/2026 Zepbound and Saxenda were removed from the Contract Drugs List (claims deny with Reject Code 70 regardless of indication; prior PAs expired 12/31/2025), and Wegovy is no longer eligible for coverage for weight loss.
Non-diabetes FDA indications remain: Wegovy requires NO approved PA for noncirrhotic MASH when billed with ICD-10 K76.0 and/or K75.8 (else denies Reject Code 80); Wegovy cardiovascular and Zepbound OSA exceptions also apply.
Members <21: weight-loss PA requests reviewed for medical necessity under the federal EPSDT benefit.
No BMI/comorbidity/lifestyle/step-therapy pathway exists because weight loss is not a benefit.
Source: DHCS Medi-Cal Rx 'GLP-1 Coverage Considerations' bulletin (administered by Prime Therapeutics State Government Solutions). View cited GLP-1 policy reference →
Note: tirzepatide is also sold as Mounjaro for type 2 diabetes, which California Medi-Cal (Medi-Cal Rx) evaluates under a separate type 2 diabetes policy (not this one) — see does California Medi-Cal (Medi-Cal Rx) cover Mounjaro?. Coverage follows the brand's FDA indication, not the molecule.
Frequently asked
- Does California Medi-Cal (Medi-Cal Rx) cover Zepbound for weight loss / obesity?
- Typically not covered. Weight loss is not and never has been a Medi-Cal-covered indication. 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 Zepbound for another payer — or draft the PA
Run Zepbound + 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.