Medi-Cal, California’s Medicaid program, provides health coverage and comprehensive prescription drug benefits for millions of residents. Ozempic, known generically as semaglutide, is a Glucagon-like peptide-1 (GLP-1) receptor agonist approved primarily for managing Type 2 Diabetes. Medi-Cal covers Ozempic, but coverage is limited to the drug’s approved medical uses for diabetes and requires meeting administrative requirements. Coverage for this high-cost injectable medication is not automatic and almost always involves Prior Authorization (PA) to ensure medical necessity and adherence to formulary guidelines.
Medi-Cal Coverage Status for Ozempic
Medi-Cal’s prescription drug benefit is managed through Medi-Cal Rx, which centralizes pharmacy coverage under a single Contract Drug List (CDL). Ozempic is included on this list, but its coverage is tightly controlled due to its high cost and high utilization rates. Coverage is restricted exclusively to the treatment of Type 2 Diabetes Mellitus, its primary FDA-approved indication. Coverage requires a clinically appropriate International Classification of Diseases (ICD-10) diagnosis code indicating Type 2 Diabetes to ensure the drug is used for improving glycemic control.
Coverage may also be granted for other non-weight loss, FDA-approved indications, such as reducing the risk of major adverse cardiovascular events in patients with established cardiovascular disease. It is important to understand the distinction between Ozempic and its counterpart, Wegovy, which contains the same active ingredient but is approved specifically for chronic weight management. Effective January 1, 2026, Medi-Cal Rx policies explicitly exclude coverage for GLP-1 drugs, including Ozempic, when they are prescribed solely for weight loss or weight-loss related indications.
Specific Requirements for Prior Authorization
Prior Authorization (PA) is required to establish medical necessity before Medi-Cal covers Ozempic. The PA requirement exists because Ozempic is considered a high-cost, non-preferred agent within the diabetes treatment algorithm. The prescribing physician must submit a formal request, often a Treatment Authorization Request (TAR), detailing the patient’s clinical history and rationale.
The most common requirement for PA approval is adherence to a step therapy protocol, meaning the patient must first try and fail less expensive, first-line diabetes medications. Standard practice dictates that a patient must have an inadequate response to or a contraindication for Metformin, a foundational oral agent. Additionally, the PA criteria often require documented failure or intolerance to a second-line oral agent, such as a sulfonylurea or a drug from the SGLT2 inhibitor class, before escalating to an injectable GLP-1 like Ozempic.
Documentation submitted by the provider must include specific laboratory evidence, such as recent A1C levels, which demonstrate that the patient’s diabetes is not adequately controlled on these preferred oral therapies. The request must clearly show a history of treatment trials, including the dose and duration of the failed medications, and the reason for failure, such as lack of efficacy or intolerable side effects. Once approved, the authorization for Ozempic is typically granted for a set period, such as one year, after which the process must be repeated for continuation of therapy.
Alternatives to Ozempic and Step Therapy Medications
If a patient does not meet the PA criteria for Ozempic, Medi-Cal requires them to use other covered diabetes treatments first. The initial step therapy typically involves Metformin, which is highly effective and low-cost as a first-line therapy. If Metformin is insufficient, the next step often involves adding a sulfonylurea, like glipizide, or a thiazolidinedione (TZD), like pioglitazone, to improve insulin sensitivity. If the patient requires an injectable GLP-1, or if the first-line oral agents are not clinically appropriate, Medi-Cal covers several alternatives to Ozempic, all subject to similar PA criteria.
Covered GLP-1 Alternatives
Other covered GLP-1 receptor agonists include:
- Trulicity (dulaglutide)
- Victoza (liraglutide)
- Byetta (exenatide)
- Mounjaro (tirzepatide)
The oral form of semaglutide, Rybelsus, is also covered for Type 2 Diabetes but must meet the same medical necessity and step therapy requirements as injectable Ozempic. A different class of agents, the SGLT2 inhibitors, such as canagliflozin or empagliflozin, are also considered preferred alternatives to GLP-1s in many cases, especially for patients with established heart or kidney disease.
Patient Costs and Pharmacy Dispensing
Once coverage for Ozempic is approved through the Prior Authorization process, the patient’s financial responsibility is typically minimal or zero. For the majority of Medi-Cal beneficiaries, the Department of Health Care Services (DHCS) does not impose copayments for prescription drugs. In rare cases, a nominal copayment of a few dollars may be required, depending on the specific eligibility category of the beneficiary. The prescription must be filled at a pharmacy that participates in the Medi-Cal program. Dispensing limits generally restrict the quantity to a 30-day supply per fill to promote proper utilization and monitoring of the medication.