Provider Alerts

Medi-Cal Rx Pharmacy Benefit Changes for all Medi-Cal Members.

Effective January 1, 2026, the following changes will be implemented to the Medi-Cal Rx Coverage Policies.

GLP-1 Drugs

The following GLP-1 drugs for the use of weight loss or weight loss-related indications will no longer be covered by Medi-Cal Rx. Starting January 1, 2026, the claims will deny at the pharmacy with Reject Code 70 – Product/Service Not Covered. Prior authorization (PA) requests will be required for all other indications of use.

• Wegovy – PA required for indication when used for noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) or cardiovascular disease.
• Zepbound – PA required when used for obstructive sleep apnea (OSA).
• Saxenda – PA required for other indication of use.

Other GLP-1 Drugs

The following GLP-1 drugs will continue to have a Code 1 diagnosis restriction of type 2 diabetes. Starting January 1, 2026, the drugs listed below will no longer be covered for weight loss or weight loss-related indications and will deny at the pharmacy with Reject Code 80 – Diagnosis Submitted Does Not Meet Drug Coverage Criteria when the Code 1 diagnosis restriction is not met. Prior authorization requests will be required for all other indications of use.

• Ozempic
• Rybelsus
• Mounjaro
• Victoza
• Byetta
• Bydureon
• Trulicity

Over the Counter (OTC) COVID-19 Antigen Tests

• PA will be required for the dispensing of OTC COVID-19 antigen test.
• PA submissions must include the following information:
• ICD-10 code.
• Signs and symptoms.
• Date of most recent COVID -19 test taken.
• Documentation of medical necessity.
• If PA is approved, allowance is a one-time fill of up to 4 tests per month.
• Excludes any prescribed by a California Children Services (CCS) Paneled Provider, for members ages 21 and under – refer to https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/publications/2025.01_A_CCS_Panel_Authority_Policy_Exclusions.pdf.
• Additional information regarding this coverage will be provided by Medi-Cal Rx after January 1, 2026.

Continuing Care

• PA will be required for drugs that are currently covered as continuation of care exceptions. Use of alternate covered drugs may be required prior to approval of the non-covered drugs.
• Impacted drugs:
• Chlorpromazine 25 mg/ml and 50 mg/2 ml ampules and vials
• Fluphenazine 2.5 mg/ml vial
• Haloperidol deconate 50 mg/ml and 100 mg/ml ampules
• Haloperidol lactate 5 mg/ml ampules, vials, and syringes
• Timolol 0.25% and 0.5% gel-solution
• Timolol maleate 0.25% and 0.5% eye solution
• Bimatoprost 0.03% eye drops
• Adhansia XR (methylphenidate) 25 mg, 35 mg, 45 mg, 55 mg, 70 mg, and 85 mg capsules

Coverage Policies for Select OTC Products

• Select OTC products, the coverage policies apply to members 21 years of age and older only. Excludes any prescribed by a CCS Paneled Provider. Refer to CCS Panel Authority Policy Exclusions List for covered drugs/products.

Updated drug coverage:

• Multivitamins combination products will no longer be covered.
• Certain single-ingredient vitamins and dry eye products will require PA with medical necessity reasons.
• Restriction of 1st and 2nd generation antihistamines to generic formulations.
• Restriction of single ingredient vitamin and antihistamines to 90 to 100 days’ supply per fill.
• OTC prenatal vitamins, limited to use during pregnancy or lactation conditions for members between ages 10 and 60 only. Restriction of 90 to 100 days’ supply for maintenance fills. First fill will be approved for only a 30-day supply to ensure medication tolerance.

Step Therapy

• Medi-Cal Rx prefers use of drugs/products listed in the “Contract Drugs List” and “Covered Products List” prior to considering approval of non-covered drugs/products. Located on the following website: https://medi-calrx.dhcs.ca.gov/home/cdl/
• Consider first covered therapies that don’t require a PA.
• If covered drug/product isn’t clinically appropriate, submit PA to establish medical necessity.
• Must include tried and considered drugs/products with reason of failure on the PA submission.
• Continuation of therapy will not suffice as justification for approval.
• This change applies to ALL members.

Additional details and resources can be found via the Medi-Cal Rx links below: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2025/12_A_30-Day_Upcoming_Changes_Medi-Cal_Rx.pdf

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