Reminder: Prior Authorization Policy Updates
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Reminds pharmacy providers and prescribers about Medi‑Cal Rx prior authorization (PA) policy updates effective January 1, 2026, including drugs not eligible for extended‑duration PAs, PA denial behavior, lookback and approval periods, and submission resources. Affects providers submitting pharmacy claims and PA requests under Medi‑Cal Rx.
A list of specific drugs and drug classes that are not eligible for extended duration prior authorizations and will deny without an approved PA (Reject Code 75).
Medi‑Cal Rx utilizes a 100‑day paid claims lookback period and up to a 12‑month PA approval period, with potential case‑by‑case longer approvals for medical necessity aligned with CCR Title 22 §51003(e).
Prior Authorization Coverage Criteria and Rules
PA coverage criteria and administrative rules
Certain drugs and drug classes are not eligible for extended-duration prior authorizations (PAs). Claims for these drugs submitted without an approved PA will deny and require a PA submission. PA approvals follow the lookback and approval period rules below.
ALL of the following
- Medi-Cal Rx uses a paid claims lookback period of 100 days for utilization management edits.
- PA approvals are generally valid for up to 12 months; certain requests may be considered for a longer approval on a case-by-case basis when medical necessity is met and aligned with CCR Title 22 §51003(e).
Claim Denial Code and Operational Timers
| Reject Code 75 | Prior Authorization Required |
Provider Submission Requirements and Guidance
PA required — claims will reject with Reject Code 75
Claims submitted for the listed drugs without an approved prior authorization will deny with Reject Code 75 (Prior Authorization Required); providers must submit a PA request for coverage consideration to avoid rejection.
Lookback period and PA approval length rules
Medi‑Cal Rx applies a 100‑day paid claims lookback and generally grants prior authorizations for up to 12 months; requests for longer approvals may be considered case‑by‑case for medical necessity consistent with CCR Title 22 §51003(e). Historical approvals outside the approval period or when paid claims history exceeds 100 days are not valid and may require a new PA.
Submission guidance and alternative therapy options
Use the Medi‑Cal Rx Web Portal resources (Contract Drugs & Covered Products Lists and the Approved NDC List) for coverage and product information; consider alternate covered therapies when clinically appropriate and, if therapy change is not appropriate, submit a PA via approved Medi‑Cal Rx submission methods.
- Refer to the Contract Drugs & Covered Products Lists page on the Medi‑Cal Rx Web Portal for coverage and Code I limitations.
- Consider alternate covered therapies that may not require a PA; consult the Medi‑Cal Rx Approved NDC List.
- If no appropriate alternative, submit a PA request using approved Medi‑Cal Rx submission methods and review PA resources on the Forms & Information page.
Policy Effective Date and Context
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