Does L.A. Care Cover Wegovy? Medi-Cal Cutoff, Plans, and Costs

Whether L.A. Care covers Wegovy depends on which L.A. Care plan you’re enrolled in and why the drug is being prescribed. If you’re on L.A. Care’s Medi-Cal plan, Wegovy is no longer covered for weight loss as of January 1, 2026, though it can still be covered for certain other diagnoses. If you’re on L.A. Care Covered through Covered California, Wegovy is on the formulary as a Tier 2 preferred brand, but only with prior authorization and only when medical necessity is documented.

Medi-Cal: No Weight-Loss Coverage After January 1, 2026

California’s 2025–26 state budget ended Medi-Cal coverage of GLP-1 drugs like Wegovy, Zepbound, and Saxenda when they’re prescribed only for weight loss. The change took effect January 1, 2026, and it runs through Medi-Cal Rx, the statewide pharmacy benefit that covers every Medi-Cal enrollee, including L.A. Care Medi-Cal members. Body mass index doesn’t create an exception; the exclusion applies regardless of BMI.¹

Prior authorizations that had been approved for weight loss expired on December 31, 2025. There is no grace period or continuing care window. Any claim submitted on or after January 1, 2026, for weight-loss use is denied automatically.²

When Medi-Cal Still Covers Wegovy

Weight loss alone is off the table, but Medi-Cal Rx still covers Wegovy for several FDA-approved uses when medical necessity is established:

Noncirrhotic MASH (metabolic dysfunction-associated steatohepatitis). As of April 1, 2026, no prior authorization is required if the prescriber includes ICD-10 codes K76.0 and/or K75.8 on the claim.³
Cardiovascular disease, if the prescriber submits a prior authorization showing medical necessity.²
Members under 21, who may still qualify for weight-loss coverage through the federal EPSDT benefit. These requests need an approved prior authorization and are reviewed case by case.¹

For any diagnosis other than MASH, the prescriber must submit a prior authorization to Medi-Cal Rx with the appropriate diagnosis code and supporting documentation in the medical record.³

L.A. Care Covered (Covered California Plans)

L.A. Care Covered and L.A. Care Covered Direct use a separate formulary from Medi-Cal. On the 2026 formulary updated January 5, 2026, Wegovy sits at Tier 2 (preferred brand) across every dosage strength: 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, and 2.4 mg.⁴

Two restrictions apply. The prescriber has to obtain prior authorization before the plan will pay, and quantities are capped at four pens per 28 days. The formulary also flags Wegovy as “excluded, except when medically necessary,” meaning approval is not automatic and depends on the prior authorization process confirming the prescription meets the plan’s medical necessity criteria.⁴

What You’ll Pay by Metal Level

Because Wegovy is Tier 2, your out-of-pocket cost tracks the metal-level plan you chose. For a 30-day retail supply in 2026:

Most of these plans also carry a pharmacy deductible before the copay takes over, typically $50 for an individual or $100 for a family.⁷ Silver 87 members should be aware of one wrinkle: that plan’s Summary of Benefits lists “weight loss programs” among services generally not covered, which may factor into whether a prior authorization for Wegovy prescribed for weight management gets approved.⁶

PASC-SEIU Plan

If you’re covered through L.A. Care’s PASC-SEIU plan for in-home support services workers, Wegovy is on the June 2026 formulary as a formulary-tier drug. It requires prior authorization, is limited to four pens per 28 days for injections and one tablet per day for oral forms, and carries the same “excluded, except when medically necessary” notation.⁹

How to Confirm Coverage for Your Plan

The most reliable way to check is to verify against your specific plan documents.

L.A. Care’s online formulary search lets you pick your plan from a dropdown and look up the drug to see tier and restrictions.¹⁰
Medi-Cal members should use the Medi-Cal Rx website through DHCS, since pharmacy benefits run there rather than through L.A. Care’s formulary tool.¹⁰
Medicare Plus members are directed to a separate Medicare formulary search tool.¹⁰
L.A. Care Member Services: 1-855-270-2327 (TTY 711).¹¹

If Medi-Cal Denies Your Wegovy

A Medi-Cal denial comes as a Notice of Action, and you have the right to request a State Hearing through the California Department of Social Services. The request generally must be filed within 90 days of the notice.²

There’s a shorter window worth knowing about. If you were already taking Wegovy on or before January 1, 2026, and you file the hearing request within 10 days of the denial notice, you may be able to keep receiving the drug while the hearing is pending. That continued coverage runs until the end of the previously approved authorization period, a hearing decision, or the hearing being withdrawn or closed, whichever comes first.²

State Hearing requests can be filed by phone at 1-800-743-8525 or 1-855-795-0634, by fax at 1-833-281-0905, or online through the CDSS hearing request portal.²

Paying Without Plan Coverage

Novo Nordisk, Wegovy’s manufacturer, runs a copay savings card, but Medi-Cal members can’t use it. The card is limited to patients with commercial insurance and explicitly excludes anyone in a federal or state health care program, including Medicaid and Medicare.¹²

L.A. Care Covered California members may qualify, because ACA marketplace plans are treated as commercial for this purpose. Eligible patients can pay as little as $25 per month, with maximum savings of $100 per 28-day supply.¹³

There’s also a self-pay route that bypasses insurance entirely. Novo Nordisk’s introductory pricing for new patients is $199 per month for the first two 28-day fills of the injectable, and the oral tablet, FDA-approved in late 2025, starts at $149 per month for lower doses.¹³ Self-pay patients must agree not to seek reimbursement from any insurance or apply the cost toward a deductible.¹²

What Could Change

Two developments are worth watching if Medi-Cal weight-loss coverage matters to you. The Centers for Medicare and Medicaid Services launched the BALANCE demonstration model, which lets state Medicaid programs cover GLP-1s for obesity if manufacturers agree to negotiated net prices. The Medicaid piece opened May 1, 2026, with a state application deadline of July 31, 2026.¹⁴ California has not announced any plan to join, and as of mid-2026 the state’s Department of Finance has said it has “no plans” to reverse the coverage cut.¹⁵

At the state level, California Senate Bill 535, the Obesity Care Access Act, was introduced in February 2025. It would require commercial health plans, including Covered California plans, to cover at least one FDA-approved anti-obesity medication with criteria no more restrictive than the FDA’s indications. The bill’s hearing was postponed in August 2025 and had not advanced further as of mid-2026.¹⁶

1
Medi-Cal Rx. State Budget Policy Updates FAQ
2
Medi-Cal Rx. GLP-1 Changes Member Notice
3
Medi-Cal Rx. Changes to GLP-1 Drug Coverage for Wegovy
4
L.A. Care Health Plan. L.A. Care Covered Formulary
5
L.A. Care Health Plan. L.A. Care Covered Plans at a Glance
6
L.A. Care Health Plan. L.A. Care Covered Silver 87 HMO Summary of Benefits and Coverage
7
L.A. Care Health Plan. L.A. Care Covered Silver 73 HMO Summary of Benefits
8
L.A. Care Health Plan. L.A. Care Covered Direct Bronze 60 HMO Summary of Benefits and Coverage
9
L.A. Care Health Plan. PASC-SEIU Formulary
10
L.A. Care Health Plan. Formulary Search
11
L.A. Care Health Plan. L.A. Care Covered Documents
12
NovoCare. Wegovy Savings Card Eligibility
13
NovoCare. Wegovy Savings Offer
14
KFF. What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid
15
KFF Health News. California Medicaid Medi-Cal GLP-1 Weight Loss Drugs Ends Coverage Cost
16
LegiScan. SB 535 Obesity Care Access Act