Reminder: Changes to Medi-Cal Pharmacy (Rx) as of January 2026
| Date: | April 29, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Practitioners, Facilities, and Hospitals |
| Type: | Informational/Educational |
| Subject: | Reminder: Changes to Medi-Cal Pharmacy (Rx) as of January 2026 |
| Business: | Medi-Cal Managed Care |
Effective January 1, 2026, the following policy updates and changes were implemented by Medi-Cal Rx. This alert serves as a reminder of the implementation.
Continuing Care
Some medications were removed from the Continuing Care policy and now require a prior authorization (PA) submission with medical necessity for approval. Refer to the Medi-Cal Rx Contract Drugs List (CDL) and weblink below for the medication names.
GLP-1 Drugs
Weight loss or weight loss-related indications for the use of GLP-1 drugs are no longer covered under Medi-Cal Rx. GLP-1 drugs continue to be covered for type 2 diabetes or other non-weight loss indicated diagnosis only.
Over the Counter (OTC) COVID-19 Antigen Tests
OTC COVID-19 antigen tests now require a prior authorization (PA). Approval will be based upon medical necessity.
Select OTC Products
Coverage policies for select OTC products have been updated. Refer to the Medi-Cal Rx CDL and weblink below for medication names.
Step Therapy
The use of non-PA required drugs/products on the Medi-Cal Rx CDL continues to be preferred prior to consideration of other PA required drugs/products. If a covered drug/product is not clinically appropriate, a PA must be submitted with medical necessity, along with the tried and considered drugs/products that do not require a PA and the reason why those drugs/products do not meet the needs of the member.
The Medi-Cal Rx CDL can be found here: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/forms-and-information/cdl/Medi-Cal_Rx_Contract_Drugs_List_FINAL.pdf
Additional details and resources can be found via this Medi-Cal Rx weblink:
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
