Medi-Cal Pharmacy (Rx) – Updates and Changes
| Date: | March 18, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Practitioners, Facilities, and Hospitals |
| Type: | Informational/Educational |
| Subject: | Medi-Cal Pharmacy (Rx) – Updates and Changes |
| Business: | Medi-Cal Managed Care |
Effective June 26, 2026, pursuant to Code of Federal Regulations (CFR), Title 42, Section 455.410(b), in order to prescribe medication(s), submit claims and/or prior authorizations (PA) for a Medi-Cal member, you are required to be enrolled in Medi-Cal Fee-for-Service (FFS) using your Type 1 National Provider Identifier (NPI). This applies to all doctors, nurses, and pharmacists that will be prescribing medication(s).
The Department of Healthcare Services (DHCS) will start initiating communication with those that are currently not enrolled. If a provider enrollment isn’t submitted and approved by June 26, 2026, pharmacy claims associated with the prescriber will be denied.
Steps to take if you’re currently not enrolled:
You must first create an account and then enroll as a Medi-Cal provider via PAVE: https://www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx
Further details and resources can be found via this Medi-Cal Rx weblink: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2026/02_A_Requirement_Provider_Enrollment_Medi-Cal.pdf
Effective fall of 2026, pursuant to the California Code of Regulations (CCR), Title 22, Section 51502, pharmacies will be required to submit an ICD-10-CM diagnosis code on all pharmacy claim adjudications. Claims without an ICD-10-CM diagnosis will be denied.
Prescribers should provide the appropriate ICD-10-CM diagnosis code(s) on the prescription to ensure access to the information for the pharmacy and document the ICD-10-CM diagnosis code(s) in the member’s electronic health records for auditing purposes.
Further details and resources can be found via this Medi-Cal Rx weblink: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2026/02_A_Reminder_Include_ICD-10_Pharmacy_Claims.pdf
For any further questions that Medi-Cal Rx is unable to assist in resolving, please contact the Health Plan Pharmacy Department at 209.461.2212 to leave a secure voicemail that will be returned within one business day.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
