Coming Soon: Updates to the Early Refill Policy
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Governance of early refill claim adjudication for Medi‑Cal Rx members age 21 and older, describing denial conditions, override exceptions, and effective dates that affect pharmacy providers and prescribers.
Early refill claims will deny with Reject Code 88 (DUR Reject Error) for overruns of refill interval thresholds and cumulative days thresholds starting August 21, 2026 for members 21 years and older.
Refill interval threshold is defined as less than 75% of previous fill (90% for opioids).
A cumulative threshold of exceeding 20 days within a 180-day period will also trigger denials.
Overrides allowed for specific claim codes (ER reason code with appropriate service/result codes, SCC 03 Vacation Supply, SCC 04 Lost Supply) and each override may be used once per 365 days; exceeding overrides causes Reject Code 75.
Members younger than 21 are not impacted at this time.
Early Refill Coverage Criteria
Early refill denial and override criteria
Early refill claims will deny with Reject Code 88 - DUR Reject Error with Reason for Service Code ER - Overutilization when ANY of the following denial conditions are met; limited coded overrides are allowed as described below.
ANY of the following
ALL of the following
- General drugs: requested refill interval is less than 75% of the previous fill
- Opioids: requested refill interval is less than 90% of the previous fill
- Cumulative days threshold exceeded: requested refill would cause cumulative days to exceed 20 days within a 180-day period for the same drug (name, strength, formulation)
ALL of the following
- Reason for Service Code ER - Overutilization when accompanied by the appropriate Professional Service Code and Result of Service Code
- Submission Clarification Code (SCC) 03 - Vacation Supply
- SCC 04 - Lost Supply
ALL of the following
- Each respective override type may be used only once within a 365-day period
- When the override limit is exceeded, the claim will reject with Reject Code 75 - Prior Authorization Required and supplemental message 'Early refill overrides exceeded.'
ALL of the following
- Effective August 21, 2026, these rules apply to members 21 years of age and older
- Members younger than 21 are not impacted at this time
Reject, Override, and Threshold Codes
| 88 | DUR Reject Error — Drug Use Review Reason for Service Code ER (Overutilization) |
| ER | Reason for Service Code ER — Overutilization (used as override when accompanied by appropriate Professional Service Code and Result of Service Code) |
| 75 | Prior Authorization Required — Early refill overrides exceeded |
| SCC 03 | Submission Clarification Code 03 — Vacation Supply (override) |
| SCC 04 | Submission Clarification Code 04 — Lost Supply (override) |
Override Procedures and Required Claim Elements
Use specified override codes and track 365‑day limits to avoid Reject Code 75
Pharmacy claims that meet early refill denial conditions may only be overridden when the claim includes one of these codes: Reason for Service Code ER – Overutilization (with the appropriate Professional Service Code and Result of Service Code), Submission Clarification Code (SCC) 03 – Vacation Supply, or SCC 04 – Lost Supply. Each override type may be used only once within a 365‑day period; if a pharmacy submits an override more than once for the same override type within 365 days, the claim will reject with Reject Code 75 – Prior Authorization Required and supplemental message “Early refill overrides exceeded.” Pharmacy providers should ensure the correct override code and any required companion service/result codes are present on the claim and track prior override use before submitting to avoid Reject Code 75.
- Allowed overrides: ER (Overutilization) with appropriate Professional Service Code and Result of Service Code; SCC 03 (Vacation Supply); SCC 04 (Lost Supply).
- Frequency limit: each override type may be used only once within a 365‑day period.
- If exceeded: claim rejects with Reject Code 75 - Prior Authorization Required and message “Early refill overrides exceeded.”
- Action for pharmacies: verify the exact override code and required companion codes are present on the claim and confirm no prior override of that type was used within the past 365 days before submitting.
Policy Definitions
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