​This memo provides updated guidance for processing claims for the GLP-1 medications Wegovy and Zepbound across ADAP client coverage categories.​

1.  ADAP Clients with Private Insurance

Pharmacies must first bill the client's primary insurance. When coverage is denied and a claim is sent to ADAP, the pharmacy will receive the rejection:

“ADAP is the insurer of last resort and must be billed after primary insurance coverage. If the primary insurer has denied coverage of WEGOVY or ZEPBOUND, please provide a copy of the denied appeal from the primary health plan to Prime (phone 800-424-5906 / fax 800-424-5927)."

Once the denied appeal is submitted, ADAP may approve coverage for twelve (12) months.​

2.  ADAP Clients with Medicare

Medicare cases require special processing due to possible dual eligibility.

•  Medi-Medi clients

Message: “If client is dually eligible for Medi-Cal ('MEDIMEDI'): Contact Prime at 800-424-5906 for override."

•  All other Medicare clients

Message: “ADAP is the insurer of last resort… Please provide a copy of the denied appeal from the primary health plan to Prime (800-424-5906 / fax 800-424-5927)."​

3.  ADAP Clients with Medi-Cal

Medi-Cal will deny GLP-1 medications; however, CDPH has approved ADAP coverage. The system will automatically override these denials, and claims will pay without requiring prior authorization or an appeal.

Approval is valid for twelve (12) months and requires resubmission every twelve (12) months to account for formulary updates and changes in Medi-Medi status.

Prime is developing automation for these processes across all coverage groups. Until automated, ADAP claims denied by a primary insurer will continue to reject in the standard manner. Prime Call Center staff have been briefed and can assist with overrides or clarify when a denied appeal is necessary.​​

(12) months to account for formulary updates and changes in Medi-Medi status.

Prime is developing automation for these processes across all coverage groups. Until automated, ADAP claims denied by a primary insurer will continue to reject in the standard manner. Prime Call Center staff have been briefed and can assist with overrides or clarify when a denied appeal is necessary.​

Please ensure all staff and contracted partners are aware of these procedures. For questions, contact your OA Advisor.

Thank you,​

Joseph Lagrama .

ADAP Branch Chief

California Department of Public Health