Medi-Cal Pharmacy (Rx) Reminder: Prior Authorization Policy Updates
| 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) Reminder: Prior Authorization Policy Updates |
| Business: | Medi-Cal Managed Care |
Effective January 1, 2026, pursuant to the enacted 2025-2026 State Budget, Department of Healthcare Services (DHCS) will implement policy updates to align with California Code of Regulations (CCR), Title 22, Section 51003(e).
- Lookback period for paid claims history will be updated from 450 days to 100 days.
- Code 1 limits will apply for certain maintenance medications. These claims may be denied with the following reject codes and will require a new prior authorization (PA) request:
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- Reject Code 60 – Product/Service Not Covered for Patient Age
- Reject Code 61 – Product/Service Not Covered for Patient Gender
- Reject Code 80 – Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria
- Prior authorizations (PA) previously approved under the Transition Policy will no longer bypass the utilization management (UM) limitations and may deny with the following reject codes and will require a new prior authorization (PA) request:
- Reject Code 78 – Cost Exceeds Maximum
- Reject Code 606 – Brand Drug/Specific Labeler Code Required
- Reject Code 76 – Plan Limitations Exceeded
- Claims without a prior authorization (PA) will be denied. The extended duration policy will no longer apply to the following drugs and drugs classes found at the below link.
To view the full Medi-Cal Rx reminder published February 6, 2026, and access the full list of effected medications, please visit:
https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2026/02_A_Reminder_Prior_Authorization_Policy_Updates.pdf
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/2026/01_A_Changes_Medi-Cal_Rx_Effective_January2026.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
