Does IEHP Cover GLP-1? Covered Drugs, Restrictions, and Appeals

IEHP does cover GLP-1 medications, but only for specific medical conditions. For Medi-Cal members, which is roughly 96% of IEHP’s 1.5 million enrollees, GLP-1 drugs are covered for type 2 diabetes and a short list of other diagnoses. They are no longer covered for weight loss in adults 21 and older. That change took effect January 1, 2026, when California eliminated Medi-Cal coverage of GLP-1 drugs prescribed solely for weight management.¹ Because IEHP Medi-Cal members fill prescriptions through the statewide Medi-Cal Rx program, the rules below apply to the great majority of IEHP members.²

Which GLP-1 Drugs IEHP Covers and for What

The current rules split the GLP-1 drugs into two groups. One group is off the formulary for weight loss entirely but can be approved for a narrow list of other conditions. The other group stays on the formulary but is restricted to type 2 diabetes.

Drugs Removed from the Formulary for Weight Loss

Wegovy (semaglutide), Zepbound (tirzepatide), and Saxenda (liraglutide) were pulled from the Medi-Cal Rx Contract Drugs List. A pharmacy claim for any of these drugs now returns a “Reject Code 70,” meaning the product is not a covered service.³ Two narrow exceptions apply for non-weight-loss conditions:

Wegovy can be approved through prior authorization for noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) or for cardiovascular disease. Effective April 1, 2026, Wegovy for MASH can be filled with the appropriate ICD-10 diagnosis code (K76.0 or K75.8). For cardiovascular disease, the prescriber must submit a prior authorization showing medical necessity.⁴
Zepbound can be approved through prior authorization for obstructive sleep apnea.²
Saxenda has no specific alternate indication called out in IEHP’s notice, though Medi-Cal Rx materials note that a prior authorization may be submitted for other FDA-approved indications.⁵

Drugs Restricted to Type 2 Diabetes

Seven GLP-1 drugs remain on the Medi-Cal Rx formulary with a diagnosis restriction limiting them to type 2 diabetes: Ozempic, Rybelsus, Mounjaro, Victoza, Byetta, Bydureon, and Trulicity. The prescriber must submit a type 2 diabetes diagnosis code with the prescription. Claims without a qualifying code are denied with “Reject Code 80.”³ Prior authorization requests for FDA-approved indications other than weight loss are reviewed case by case for medical necessity.²

Obesity alone, regardless of a member’s BMI, does not qualify as a covered indication under the current policy. Any prior authorizations approved for weight-loss use before the change expired on December 31, 2025.⁶

Members Under 21

Federal law requires state Medicaid programs to cover medically necessary treatments for enrollees under 21 through the Early and Periodic Screening, Diagnostic, and Treatment benefit, usually called EPSDT. Under this rule, IEHP members younger than 21 can still receive GLP-1 drugs for weight loss when a provider submits a prior authorization and it is approved on medical necessity grounds.⁶ This is the only situation in which weight loss itself can still be the basis for coverage.

How to Request Coverage or Appeal a Denial

Members cannot file a prior authorization on their own. The prescriber or pharmacy provider has to submit it to Medi-Cal Rx. You can check whether a request has been filed by calling the Medi-Cal Rx Customer Service Center at 1-800-977-2273.⁷

If coverage is denied, you will receive a Notice of Action. You have 90 days from that notice to request a State Hearing through the California Department of Social Services.⁶

If you were already taking one of these drugs on or before January 1, 2026, there is an additional option. File your hearing request within 10 days of receiving the denial notice and specifically ask for “aid paid pending” (also called “aid to continue”). If you do, you may keep receiving the medication while the hearing is pending. That continued coverage lasts until the earlier of the end of the original prior authorization period, the hearing decision, or withdrawal of the hearing request.⁷

If You Have IEHP DualChoice or IEHP Covered California

The Medi-Cal Rx rules above apply to IEHP’s Medi-Cal plan. IEHP’s other two plans run on different pharmacy benefit structures.⁸

DualChoice is a Medicare-Medicaid dual-eligible special needs plan, so prescriptions run through a Medicare Part D formulary. Federal law has historically barred Part D from covering drugs prescribed for weight loss, though Part D generally covers GLP-1 medications for approved conditions such as type 2 diabetes, cardiovascular risk reduction, and sleep apnea.⁹ Starting July 1, 2026, a new federal program called the Medicare GLP-1 Bridge offers temporary access to Wegovy, Zepbound, and Foundayo for weight loss at a $50 monthly copay for Medicare beneficiaries who meet BMI and health-risk criteria. The Bridge operates outside standard Part D benefits and is available to enrollees in special needs plans like DualChoice.¹⁰ For eligibility and enrollment, call IEHP Member Services at 1-877-273-IEHP (4347).

IEHP Covered California pharmacy benefits are managed by MedImpact Healthcare Systems under a separate formulary and are not subject to Medi-Cal Rx restrictions.¹¹ To check whether a specific GLP-1 is covered and what prior authorization or tier requirements apply, search the IEHP Covered California formulary online or call IEHP Member Services at 1-855-433-4347.

1
Medi-Cal Rx. Important Update: GLP-1s Weight Loss Not Covered Benefit
2
IEHP Provider Services. GLP-1 Coverage Considerations Effective January 2026
3
Medi-Cal Rx. Changes to Medi-Cal Rx Effective January 2026
4
Medi-Cal Rx. State Budget Policy Updates FAQ
5
Health Plan of San Joaquin. Changes to Medi-Cal Rx 30-Day Countdown
6
Medi-Cal Rx. GLP-1 Changes
7
Medi-Cal Rx. Members State Budget Policy Updates FAQ
8
IEHP. Inland Empire Health Plan
9
Medicare Rights Center. GLP-1 Weight Loss Drug Demonstration Begins July 2026
10
CMS. Medicare GLP-1 Bridge
11
IEHP. Covered California Prescription Drugs