Partnership HealthPlan of California does not cover Zepbound for weight loss. As of January 1, 2026, Medi-Cal removed Zepbound (tirzepatide) from its Contract Drugs List when prescribed for weight management in adults 21 and older, and that change applies to every Medi-Cal member, including those enrolled in Partnership. Coverage is still possible in one situation: when a prescriber requests prior authorization to treat moderate to severe obstructive sleep apnea in an adult with obesity.1Medi-Cal Rx (DHCS). Changes to Medi-Cal Rx Effective January 2026
Pharmacy claims for Zepbound submitted for weight loss now come back with a rejection (Reject Code 70).2Partnership HealthPlan of California. GLP-1 Coverage Changes Outpatient pharmacy for Partnership members is run statewide by Medi-Cal Rx, not by Partnership itself, so requests and appeals related to Zepbound go through the state pharmacy benefit rather than the health plan’s own pharmacy team.3Partnership HealthPlan of California. Rx Corner Provider Newsletter, Winter 2025-26
When Zepbound Can Still Be Covered
The FDA approved Zepbound for moderate to severe obstructive sleep apnea in adults with obesity on December 20, 2024, and that indication is separate from weight loss.4FDA. FDA Approves First Medication for Obstructive Sleep Apnea Medi-Cal Rx reviews sleep apnea prior authorization requests case by case.5CPHA. Updates to the Medi-Cal Rx Contract Drugs List Regarding GLP-1s
A prior authorization request needs real clinical documentation. That means a drug history listing what has already been tried with dates and outcomes, relevant lab results, documentation of comorbidities, and an Atherosclerotic Cardiovascular Disease risk score where appropriate. Requests filed as “continuation of therapy” with nothing else attached will be denied.3Partnership HealthPlan of California. Rx Corner Provider Newsletter, Winter 2025-26
One other opening: Medi-Cal members younger than 21 may still qualify for a GLP-1 for weight loss with an approved prior authorization, because federal law requires states to cover medically necessary treatments for children and adolescents under the Early and Periodic Screening, Diagnostic, and Treatment benefit.6Medi-Cal Rx (DHCS). GLP-1 Changes for Medi-Cal Members
Zepbound does not qualify for coverage under a type 2 diabetes diagnosis. Some other GLP-1 drugs, such as Ozempic and Mounjaro, remain covered when the prescriber submits a diabetes diagnosis code, but Zepbound is not FDA-approved for diabetes; that indication belongs to Mounjaro, which contains the same active ingredient under a different label.7FDA. Zepbound Prescribing Information
Existing Patients Were Not Grandfathered
Adults who had been taking Zepbound for weight loss before the change did not get a transition period. Every prior authorization for that use expired on December 31, 2025, and prescriptions have not been covered since, no matter how long the patient had been on the drug.8Medi-Cal Rx (DHCS). GLP-1 Drugs Members FAQs
There is a narrow safeguard for members already on the drug. If you were taking a GLP-1 on or before January 1, 2026, and you receive a Notice of Action denying continued coverage, you can request a State Hearing. File that request within 10 days of the notice, and you may continue receiving the medication while the hearing is pending, until the hearing decision comes down, your existing prior authorization period ends, or the hearing is withdrawn.6Medi-Cal Rx (DHCS). GLP-1 Changes for Medi-Cal Members
How to Appeal a Denial
If Medi-Cal Rx or Partnership denies your Zepbound request, you have several options.
- Internal appeal. File within 60 calendar days of the Notice of Action. Partnership has 30 calendar days to decide. If the denial rests on medical necessity, a physician reviews the appeal.9Partnership HealthPlan of California. Utilization Management Appeal Policy
- Expedited appeal. When a delay could seriously jeopardize your health, a decision must come within 72 hours.10Partnership HealthPlan of California. Grievance and Appeals
- State Fair Hearing. After the internal appeal, you can request a hearing before an Administrative Law Judge through the California Department of Social Services. The general deadline is 90 days from the Notice of Action.6Medi-Cal Rx (DHCS). GLP-1 Changes for Medi-Cal Members
Partnership Member Services can be reached at (800) 863-4155, and complaints can also be filed 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
Assistance programs from Eli Lilly are largely closed to Medi-Cal members. The Zepbound Savings Card and self-pay savings programs 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 list Zepbound.12FindHonestCare. Zepbound Patient Assistance
For members willing to pay cash, LillyDirect, Eli Lilly’s direct-to-consumer pharmacy, sells Zepbound from $299 per month for the 2.5 mg starter dose up 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 roughly $350 per month with no insurance or income requirements.12FindHonestCare. Zepbound Patient Assistance
Why the Coverage Was Cut
The change came from the 2025-26 state budget package signed by Governor Gavin Newsom on June 27, 2025, which included the health omnibus trailer bill AB 116.13California Chronic Care Coalition. Major Health Care Provisions: The Health Omnibus Trailer Bill State officials estimated that continuing to cover GLP-1 drugs for weight loss would cost California $85 million in fiscal year 2025-26, rising to $680 million annually by 2028-29.14CalMatters. Medi-Cal Coverage of Weight Loss Drugs Federal Medicaid law treats weight-loss drugs as an optional benefit, so California could drop coverage without losing federal matching funds.15Legislative Analyst’s Office. Medi-Cal Pharmacy Spending Report
The Obesity Society called the cut “discrimination against plan beneficiaries” and argued the state’s projected savings relied on gross drug prices without accounting for manufacturer rebates or federal matching funds.16The Obesity Society. TOS Opposes Elimination of Medi-Cal Coverage of GLP-1s
Whether coverage might return is unclear. As of early 2026, only 13 state Medicaid programs covered GLP-1 drugs for obesity.17KFF. Medicaid Coverage of and Spending on GLP-1s A voluntary CMS demonstration called the BALANCE model negotiates lower GLP-1 prices with manufacturers, includes Zepbound, and is open to state Medicaid applications through July 31, 2026, but there is no public indication that California’s Department of Health Care Services has applied.18CMS. BALANCE Model For now, sleep apnea prior authorization and the appeal process are the practical routes for any Partnership member who still needs the medication.