Medi-Cal Pharmacy (Rx) – Updates to Early Refill Policy
| Date: | July 22, 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 to Early Refill Policy |
| Business: | Medi-Cal Managed Care |
Effective August 21, 2026, Medi-Cal Rx will be making some changes to the early refill policy for members 21 years and older. Claims that do not meet the refill thresholds and/or cumulative days thresholds will deny with Reject Code 88 – DUR Reject Error with Drug Use Review (DUR) Reason for Service Code ER – Overutilization and will be subject to override limits.
Reasons for rejection:
- Member has not used up at least 75% of the previous fill of the same medication in name, strength, and formulation. Opioids are at 90% completion.
- Member has not used up a threshold of more than a 20 day supply on a previous fill of the same medication in name, strength, and formulation during a 180-day period.
Exceptions override (one time override per 365 days):
- Reason for Service Code ER – Overutilization (with the appropriate Professional Service Code and Result of Service Code)
- Submission clarification code (SCC) value of 03 – Vacation Supply
- SCC 04 – Lost Supply
For additional detailed information, please visit weblink: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/2026/07_A_ Coming_Soon_Updates_Early_Refill_Policy.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
