Medi‑Cal Rx: Pharmacy coverage and prior authorization updates (OTC products, continuing care, step therapy, GLP‑1 guidance)
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Summarizes Medi‑Cal Rx coverage updates effective Jan 1, 2026 and related guidance for pharmacy providers and prescribers under Health Plan of San Joaquin, including OTC product rules, continuing care removals, step therapy expectations, and GLP‑1 coverage restrictions.
Medi‑Cal Rx updates effective January 1, 2026 change coverage and prior authorization requirements for select OTC products, continuing care drugs, step therapy expectations, and GLP‑1 agents.
Zepbound and Saxenda have been removed from the Contract Drugs List and will deny as not covered for weight‑loss indications.
GLP‑1 drugs remain covered for type 2 diabetes and other allowable diagnoses; Wegovy added coverage for noncirrhotic MASH effective April 1, 2026 when billed with the correct ICD‑10‑CM code.
Coverage criteria summary
Coverage summary
Coverage changes and conditions
See source for product lists and age limits.
Prenatal multivitamins also have a Code I diagnosis restriction for pregnancy or lactation.
Medi‑Cal Rx no longer covers any GLP‑1 drugs for weight‑loss or weight‑loss related indications. Specifically, Zepbound and Saxenda have been removed from the Contract Drugs List and will deny with Reject Code 70 as "Product/Service Not Covered," although limited exceptions may apply.
Use of GLP‑1 receptor agonists for weight loss or weight‑loss related indications is considered not covered / not medically necessary under Medi‑Cal Rx. Other GLP‑1 agents continue to be covered only for type 2 diabetes or other allowable non‑weight loss diagnoses; claims that do not meet these coverage criteria will deny per the reject codes noted below.
Coding, quantity and supply rules
| 70 | Reject Code 70 - Product/Service Not Covered |
| 80 | Reject Code 80 - Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria |
Required provider actions and authorization guidance
PA required for select OTC tests and continuing-care drugs; show medical necessity
Prior authorization (PA) is required for select OTC COVID-19 antigen tests for all members and for multiple OTC and continuing-care drugs removed from automatic coverage; PA requests must demonstrate medical necessity. OTC COVID-19 antigen tests may be approved only for medical necessity unless prescribed by a California Children’s Services (CCS) paneled provider for members younger than 21 years. Refer to the Contract Drugs List (CDL) for the full lists of OTC and continuing-care products that now require PA.
- OTC COVID-19 antigen tests: PA required for all members; exception if prescribed by a CCS-paneled provider for members <21.
- Continuing-care drugs removed from automatic coverage (see CDL) now require an approved PA demonstrating medical necessity.
Follow CDL first; document failures when requesting non-preferred drugs
Prescribers should follow step therapy expectations by preferentially using drugs listed on the Contract Drugs List (CDL) before requesting non-preferred agents via PA. If a covered CDL product is clinically inappropriate, submit a PA request that documents prior therapies tried and why they failed or are unsuitable.
- Consider prescribing covered therapies that may not require PA.
- If non-preferred agent is requested, document why CDL-listed options are not appropriate.
Document prior therapies and reasons in PA to establish medical necessity
PA requests must establish medical necessity by listing drugs/products tried and considered and explaining the reason(s) those therapies do not meet the member's needs; continuation of therapy alone is insufficient justification for approval.
- Include specific prior drugs/products tried and clinical reasons they were ineffective or not tolerated.
- Continuation of therapy (prior or current use) does not by itself justify PA approval.
Prenatal vitamins: Code I diagnosis and 90–100 day supply after initial fill
Prenatal multivitamins require a Code I diagnosis restriction for pregnancy or lactation and are limited to a 90–100 day supply per fill after an initial approvable shorter tolerability fill.
- Initial fill may be for less than 90 days to ensure tolerability.
- Subsequent fills/refills must meet the minimum 90–100 day supply per fill.
GLP‑1 claim denials: removed products deny Code 70; Wegovy needs ICD‑10 or Code 80
Claims for GLP‑1 products removed from the CDL for weight‑loss (for example, Zepbound and Saxenda) will deny with Reject Code 70; Wegovy claims submitted without an allowable ICD‑10‑CM diagnosis for noncirrhotic MASH will deny with Reject Code 80.
- Zepbound and Saxenda: claims will deny with Reject Code 70 - Product/Service Not Covered.
- Wegovy: effective 4/1/2026 is covered for noncirrhotic MASH only when billed with the corresponding ICD‑10‑CM; missing allowable ICD‑10-CM will deny with Reject Code 80 - Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria.
Definitions and age-based restrictions
Initial therapy coverage rules
Initial fill guidance
Initial fill allowances
Subsequent fills require a 90- to 100-day supply per fill.
If a covered drug/product is not clinically appropriate, submit a PA request establishing medical necessity and document prior therapies tried.
Continuation of therapy criteria
Continuation of therapy guidance
Continuation of therapy does not alone justify PA approval.
Applies to all members regardless of eligibility, age, or program enrollment.
Step therapy and preferred products
| Step | Expectation / Requirement | Provider action |
|---|---|---|
| 1 | Medi‑Cal Rx prefers drugs/products listed on the Contract Drugs List (CDL) prior to considering approval of non‑preferred agents that require prior authorization. | Prescribe CDL‑listed products when clinically appropriate to avoid PA; if a CDL product is not appropriate, submit a PA request documenting medical necessity and prior therapies tried. |
| 2 | Consider prescribing covered therapies that may not require prior authorization to reduce administrative burden and delays. | Review the Contract Drugs & Covered Products Lists and select an alternative covered product when appropriate before initiating a PA for a non‑preferred agent. |
| 3 | When requesting a non‑preferred drug via PA, providers must document drugs/products tried and the reason(s) they do not meet the member's needs; continuation of therapy alone is insufficient justification for approval. | Include prior therapies tried, clinical rationale for why those therapies failed or are unsuitable, and any supporting clinical documentation with the PA request. |
Quantity limits and supply rules
Site-of-care rules
PA required for OTC COVID‑19 antigen tests unless CCS‑prescribed for <21
OTC COVID‑19 antigen tests require prior authorization for all members; approval may be granted only for medical necessity unless the test is prescribed by a California Children’s Services (CCS) paneled provider for members younger than 21 years.
- Submit PA demonstrating medical necessity for OTC COVID‑19 antigen tests for members ≥21 or when not prescribed by a CCS‑paneled provider.
- For members <21, if prescribed by a CCS‑paneled provider the PA requirement is not applicable.
Policy background
These coverage changes reflect State Budget‑driven updates implemented by DHCS that modify Medi‑Cal Rx rules for GLP‑1 agents. As part of those changes, Wegovy will be covered for noncirrhotic metabolic dysfunction‑associated steatohepatitis (MASH) effective April 1, 2026 when submitted with the appropriate ICD‑10‑CM diagnosis code; claims for Wegovy submitted without an allowable ICD‑10‑CM code will deny with Reject Code 80.
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