Health Net GLP-1 Coverage & Prior-Authorization Guide (2026)

Health Net, a Centene subsidiary, covers Californians across several distinct lines of business — Medi-Cal managed care, Ambetter Marketplace, and commercial large-group employer plans — and GLP-1 coverage no longer looks the same across them. Two policy changes took effect January 1, 2026: California's Medi-Cal Rx program dropped weight-loss GLP-1s from coverage entirely, while Health Net's commercial and Ambetter Marketplace plans kept Wegovy, Zepbound, and Saxenda on formulary but tightened the prior-authorization criteria. We pulled the primary Medi-Cal Rx and Health Net provider-bulletin sources directly on 2026-07-10 and quote them verbatim below.

The bottom line

• Medi-Cal (Health Net's Medi-Cal managed-care line): effective 1/1/2026, weight-loss GLP-1s — Wegovy, Zepbound, and Saxenda — are no longer covered. This follows California's statewide Medi-Cal Rx policy, not a Health Net-specific decision.
• Commercial and Ambetter Marketplace: weight-loss GLP-1s can still be covered, but criteria tightened as of 1/1/2026 — prior authorization plus enrollment in a Health Net-approved weight-loss program, with BMI 40+ clearly eligible and BMI 30-40 dependent on the specific plan's benefits.
• Diabetes GLP-1s are unaffected either way: Ozempic, Mounjaro, Rybelsus, Victoza, Byetta, Bydureon, and Trulicity remain covered for type 2 diabetes with a diagnosis code, on both Medi-Cal and commercial/Marketplace lines.
• A handful of Medi-Cal exceptions still allow a weight-loss GLP-1 with a diagnosis code or PA — noncirrhotic MASH (Wegovy), cardiovascular disease (Wegovy, via PA), obstructive sleep apnea (Zepbound, via PA), and members under 21 through the federal EPSDT benefit.

What Health Net actually covers

Medi-Cal: weight-loss GLP-1s dropped effective 1/1/2026

Health Net's Medi-Cal members are subject to Medi-Cal Rx, California's statewide fee-for-service pharmacy benefit — the same policy that applies to every other Medi-Cal managed-care plan, not something Health Net set independently. Effective January 1, 2026, Medi-Cal Rx removed GLP-1s for weight-loss-only use: Wegovy, Zepbound, and Saxenda are no longer covered for weight loss, and every previously approved prior authorization for weight loss ended on 12/31/2025. Claims for weight-loss GLP-1s filed on or after 1/1/2026 deny with Reject Code 70 and the message "GLP-1s for weight loss are not covered."

• Exceptions that remain covered with a diagnosis code or PA: Wegovy for noncirrhotic MASH, and (via PA) Wegovy for cardiovascular disease; Zepbound for obstructive sleep apnea, also via PA.
• Diabetes drugs are untouched: Ozempic, Rybelsus, Mounjaro, Victoza, Byetta, Bydureon, and Trulicity remain covered for type 2 diabetes as long as the prescriber submits a diagnosis code.
• Members under 21 may still get a weight-loss GLP-1 approved through the federal EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) benefit with an approved PA.

Commercial and Ambetter Marketplace: still covered, with tightened PA

Health Net provider bulletin 25-1150, effective 1/1/2026, tightened weight-loss-drug criteria for large-group employer HMO/POS plans, large-group PPO plans, and Ambetter Individual & Family Plans (Marketplace) — it does not touch small-group plans. Wegovy, Zepbound, and Saxenda stay on formulary for these members with prior authorization.

• BMI ≥ 40 (Class III severe obesity): eligible for coverage with PA plus enrollment in a Health Net-approved weight-loss program.
• BMI 30-40: coverage depends on the specific plan's benefits — verify before prescribing rather than assuming coverage.
• PA is required for all covered weight-loss medications on these lines of business, with no exceptions carved out in the bulletin.

Prior authorization criteria

• Commercial/Marketplace (Ambetter IFP + large-group HMO/POS/PPO): prior authorization required for all covered weight-loss medications.
• Commercial/Marketplace: BMI ≥ 40 is eligible with PA; BMI 30-40 depends on the member's specific plan benefits — verify before prescribing.
• Commercial/Marketplace: the member must be enrolled in a prescriber-recommended or Health Net-approved weight-loss program — reduced-calorie diet, increased physical activity, and behavioral modification.
• Commercial/Marketplace continuation: the PCP must continue to maintain the obesity prescription and the member must stay enrolled in an approved weight-loss program.
• Medi-Cal: weight-loss-only GLP-1s have no PA pathway, except Wegovy for MASH, Wegovy for cardiovascular disease via PA, Zepbound for obstructive sleep apnea via PA, and members under 21 via an approved EPSDT PA. Diabetes GLP-1s require a type 2 diabetes diagnosis code instead of a weight-loss PA.

"If you take Wegovy for weight loss only, it is no longer covered. Previously approved requests from your pharmacy provider or prescriber, called prior authorizations (PAs), ended on December 31, 2025."

— Medi-Cal Rx, "Changes to GLP-1 Drug Coverage, Effective January 1, 2026" (member notice)

"If you take Ozempic, Rybelsus, Mounjaro, Victoza, Byetta, Bydureon, or Trulicity for type 2 diabetes, it will continue to be covered if your prescriber submits a diagnosis code with your prescription."

— Medi-Cal Rx, "Changes to GLP-1 Drug Coverage, Effective January 1, 2026"

"Members with Class III severe obesity (BMI >= 40) continue to be eligible for coverage with prior authorization (PA) and with enrollment in a Health Net-approved weight loss program."

— Health Net Provider bulletin 25-1150, "Weight Loss Medications Coverage Criteria, Effective January 1, 2026"

"For members with BMI between 30 and 40, coverage for weight loss medication will depend on their plan benefits—please verify coverage before prescribing."

— Health Net Provider bulletin 25-1150, "Weight Loss Medications Coverage Criteria, Effective January 1, 2026"

How to appeal a denial

Medi-Cal: a denied member receives a Notice of Action and can request a California DHCS/CDSS State Hearing, generally within 90 days of the notice, in writing. Members who were already taking a GLP-1 on or before 1/1/2026 and request a State Hearing within 10 days of the notice can keep receiving the drug — aid-paid-pending — until the PA end date, the hearing decision, or withdrawal of the request.

Commercial and Ambetter Marketplace: start with Health Net's standard internal grievance/appeal process. If that is denied, California DMHC-regulated plans offer an Independent Medical Review (IMR) through the DMHC Help Center — typically pursued after the internal appeal, though urgent cases can go straight to IMR.

The DMHC IMR path and the specific commercial grievance/IMR deadlines cited above come from California regulatory sources, not a Health Net-specific member document, and some employer (ERISA/self-funded) plans route to a federal external-review process instead of DMHC IMR. Medicare is governed separately — Part D generally excludes weight-loss-only GLP-1s. Formulary tiers and copays were not located in primary sources. This article is informational and does not constitute medical, legal, or insurance-coverage advice — verify your specific plan document before relying on anything above.

Further reading

• Aetna GLP-1 prior authorization guide — how a national commercial insurer structures its GLP-1 PA bulletins, for comparison against Health Net's California-specific rules.
• Best semaglutide providers — our verified telehealth provider directory for cash-pay or bridge-therapy options.
• Best tirzepatide providers — verified telehealth providers offering Zepbound and compounded tirzepatide.

References

1. Medi-Cal Rx — Changes to GLP-1 Drug Coverage, Effective January 1, 2026 (member notice)
2. Health Net Provider bulletin 25-1150 — Weight Loss Medications Coverage Criteria, Effective January 1, 2026