Partnership HealthPlan of California does not cover Zepbound for weight loss. Since January 1, 2026, Medi-Cal has excluded Zepbound and other GLP-1 drugs when prescribed solely for weight management in adults 21 and older. Coverage is still possible, with prior authorization, when Zepbound is prescribed to treat moderate to severe obstructive sleep apnea in an adult with obesity.
What Changed for Weight-Loss Prescriptions
Zepbound (tirzepatide) was removed from the Medi-Cal Rx Contract Drugs List effective January 1, 2026, alongside Wegovy and Saxenda.1Medi-Cal Rx (DHCS). Changes to Medi-Cal Rx Effective January 2026 Pharmacy claims submitted for Zepbound for weight loss now return a rejection (Reject Code 70).2Partnership HealthPlan of California. GLP-1 Coverage Changes Any prior authorization previously approved for a weight-loss use of these drugs expired on December 31, 2025.
Zepbound is not FDA-approved for type 2 diabetes. That matters because other GLP-1 drugs that share this family, including Ozempic, Mounjaro, Rybelsus, Trulicity, Victoza, Byetta, and Bydureon, remain covered when a prescriber submits a type 2 diabetes diagnosis code with the prescription.3Medi-Cal Rx (DHCS). GLP-1 Changes for Medi-Cal Members Mounjaro contains the same active ingredient as Zepbound (tirzepatide) but is labeled for diabetes; Zepbound is not.4FDA. Zepbound Prescribing Information
When Zepbound Is Still Covered
Zepbound has two FDA-approved uses: chronic weight management, and the treatment of moderate to severe obstructive sleep apnea in adults with obesity. The FDA approved the sleep apnea indication on December 20, 2024.5FDA. FDA Approves First Medication for Obstructive Sleep Apnea
Because sleep apnea is a separate indication from weight loss, Medi-Cal Rx will consider covering Zepbound on a case-by-case basis when a provider submits a prior authorization request for obstructive sleep apnea.6CPHA. Updates to the Medi-Cal Rx Contract Drugs List Regarding GLP-1s
Medi-Cal members younger than 21 may also remain eligible for GLP-1 drugs for weight loss if a prior authorization is submitted and approved. Federal law requires states to cover medically necessary treatments for children and adolescents under the Early and Periodic Screening, Diagnostic, and Treatment benefit.3Medi-Cal Rx (DHCS). GLP-1 Changes for Medi-Cal Members
How a Sleep Apnea Prior Authorization Gets Filed
Prior authorization requests go through Medi-Cal Rx, not Partnership. Outpatient pharmacy benefits for all Medi-Cal managed care members are administered statewide by Medi-Cal Rx, the fee-for-service pharmacy program run by the Department of Health Care Services.7Partnership HealthPlan of California. Rx Corner Provider Newsletter, Winter 2025-26
The request has to include clinically relevant documentation:
- A list of other drugs tried for the condition, with dates and outcomes.
- Relevant lab results supporting the diagnosis.
- Documentation of the patient’s comorbidities.
- An Atherosclerotic Cardiovascular Disease risk score, where appropriate.
Requests submitted as a bare “continuation of therapy” without supporting clinical documentation will be denied.7Partnership HealthPlan of California. Rx Corner Provider Newsletter, Winter 2025-26 The current coverage criteria are posted on the Medi-Cal Rx Bulletins and News page at medi-calrx.dhcs.ca.gov.
If You Were Already Taking Zepbound
Adults who were already on Zepbound for weight loss when the policy took effect did not get a transition period. Existing prior authorizations expired on December 31, 2025, and prescriptions for weight-loss use have not been covered since, no matter how long the patient had been on the medication.8Medi-Cal Rx (DHCS). GLP-1 Drugs Members FAQs
One narrow protection exists. A member who was taking a GLP-1 drug on or before January 1, 2026, and who receives a Notice of Action denying continued coverage can request a State Hearing. If the request is filed within 10 days of receiving the notice, the medication may continue while the hearing is pending, until the hearing decision is issued, the existing prior authorization period ends, or the hearing is withdrawn.3Medi-Cal Rx (DHCS). GLP-1 Changes for Medi-Cal Members
How to Appeal a Denial
If you receive a denial for Zepbound, there is a structured path to challenge it.
- File an internal appeal with Partnership within 60 calendar days of the Notice of Action. Partnership has 30 calendar days to decide. If the denial rested on medical necessity, a physician reviews the appeal.9Partnership HealthPlan of California. Utilization Management Appeal Policy
- Request an expedited appeal if a delay could seriously jeopardize your health. A decision must come within 72 hours.10Partnership HealthPlan of California. Grievance and Appeals
- After the internal appeal, request a State Fair Hearing before an Administrative Law Judge through the California Department of Social Services. Members generally have 90 days from the Notice of Action to request one.3Medi-Cal Rx (DHCS). GLP-1 Changes for Medi-Cal Members
Partnership Member Services can be reached at (800) 863-4155, and appeals can also be filed online through the Partnership member portal. Free legal help is available through Legal Services of Northern California at (888) 354-4474.10Partnership HealthPlan of California. Grievance and Appeals
Paying Out of Pocket
Options outside Medi-Cal are limited. Eli Lilly’s Zepbound Savings Card and self-pay savings programs explicitly exclude anyone enrolled in a government-funded healthcare program, including Medicaid.11Eli Lilly. Zepbound Coverage and Savings The Lilly Cares patient assistance program does not currently include Zepbound on its list of available drugs.12FindHonestCare. Zepbound Patient Assistance
Patients who are uninsured or willing to pay cash can order Zepbound through LillyDirect, Eli Lilly’s direct-to-consumer pharmacy, at prices ranging from $299 per month for the 2.5 mg starter dose to $449 per month for maintenance doses of 7.5 mg through 15 mg. A separate program called TrumpRx, launched in early 2026, offers Zepbound at approximately $350 per month with no insurance or income requirements.12FindHonestCare. Zepbound Patient Assistance
Why Partnership Points You to Medi-Cal Rx
Partnership manages medical benefits, meaning drugs administered in clinical settings like physician offices and hospitals. Outpatient pharmacy benefits for its members are handled by Medi-Cal Rx.7Partnership HealthPlan of California. Rx Corner Provider Newsletter, Winter 2025-26 The Zepbound decision was made at the state level by DHCS and applies to every Medi-Cal member in California, not just Partnership enrollees. That is why the coverage rules, the sleep apnea prior authorization pathway, and the aid-paid-pending option all run through Medi-Cal Rx rather than through Partnership directly.