The facts
Weight loss
Excluded
Type 2 diabetes
Not indicated
Prior auth
Required (sleep apnea)
Typical cost
Plan-specific
The criteria, as published
3 of 9 criteria are stated in the Medi-Cal documents we read. Tap a row for the exact wording. Where a cell says not published, the documents we read do not say, and the line under it is how to find out.
- Formulary status
- Not published in what we readLook Zepbound up in your plan's drug list or price tool, or call the number on your card.
- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Zepbound.
- Qualifying conditions
Obstructive sleep apnea, through a PA request
“Talk to your pharmacy provider or prescriber about submitting a PA request if you take Zepbound for obstructive sleep apnea (OSA).”
medi-calrx.dhcs.ca.gov · 2026-10-03- Lifestyle program
- Not published in what we readAsk whether a diet, exercise or behavioral program has to be documented, and for how long.
- Step therapy
- Not published in what we readAsk whether another drug has to be tried before Zepbound.
- Quantity limit
- Not published in what we readAsk what quantity limit applies to each fill.
- Renewal
- Not published in what we readAsk how long an approval lasts and what the renewal needs.
- Plan can exclude it?
Yes: no longer covered for weight loss only
“If you take one of these drugs for weight loss only, it is no longer covered. Previously approved PAs from your pharmacy provider or prescriber ended on December 31, 2025.”
medi-calrx.dhcs.ca.gov · 2026-10-03- 2026 change
Weight-loss-only prior authorizations ended Dec 31, 2025
“If you take one of these drugs for weight loss only, it is no longer covered. Previously approved PAs from your pharmacy provider or prescriber ended on December 31, 2025.”
medi-calrx.dhcs.ca.gov · 2026-10-03
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager
No single PBM to name here, which is itself the finding. Different plans under this name use different benefit managers, so one national statement about the formulary would be wrong.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
How prior authorization works here
Six steps. Specifics come from the criteria above; where Medi-Cal does not publish one, the step says what to ask for.
- 1
Confirm the benefit exists
Before any paperwork, ask whether your plan includes the weight-loss drug benefit. On whether a plan can leave it out, the documents say: Yes: no longer covered for weight loss only.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Zepbound, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
Current and baseline BMI, with dates. Conditions: Obstructive sleep apnea, through a PA request. Records of any diet, exercise or behavioral program.
- 4
Answer step therapy, if there is any
Ask whether another drug must come first. If you have already tried one, the request should list it with dates and the reason it stopped.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Our Zepbound prior authorization letter template covers the cover letter. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
Ask how long the approval lasts and what the renewal needs, so the gap does not catch you out.
Get your real answer
If you take Zepbound for sleep apnea, ask your prescriber to submit a prior authorization request to Medi-Cal Rx. For weight only, Medi-Cal will not pay, and the cheapest cash programs below are the route.
Coverage is plan-specific: this page reports what Medi-Cal publishes, not a promise about your plan. Not medical or insurance advice.
