A prior-authorization problem is easier to solve when everyone is working from the same information. Before the next fill, patients should know the exact medication and dosage form, when the current supply will run out, who is prescribing it, whether a PA has already been submitted, and whether Medi-Cal Rx has issued a claim rejection or Notice of Action.
Quick Answer
Beginning January 1, 2026, selected medications that previously qualified for Medi-Cal Rx continuing-care exceptions now require an approved prior authorization demonstrating medical necessity. The affected list includes specified forms or strengths of chlorpromazine, fluphenazine, haloperidol decanoate, haloperidol lactate, timolol, timolol maleate, bimatoprost 0.03%, and Adhansia XR. Medi-Cal Rx prefers covered alternatives that do not require PA before approving a PA-required product. If an alternative is not clinically appropriate, the provider’s PA should identify drugs or products that were tried or considered and explain why they do not meet the member’s needs. Simply stating that the patient has used the medication before is not enough by itself. Medi-Cal Rx says it generally reviews PA requests within 24 hours, and an eligible member who needs the medication right away may qualify for an emergency fill of up to 14 days.
What Changed on January 1, 2026
As part of California’s 2025–26 State Budget implementation, Medi-Cal Rx removed selected drugs and products from its continuing-care policy. These medications now require an approved PA demonstrating medical necessity before ongoing coverage can continue.
This change applies to all Medi-Cal members, regardless of age, eligibility category, or specialty-program enrollment.
What is happening with the next refill?
PA now required
Confirm the exact medication and dosage form, ask whether the prescriber has been contacted, and find out whether the PA needs documentation about alternatives that were tried or considered.
PA submitted
Ask whether Medi-Cal Rx has received the request, whether more clinical information is needed, and when the pharmacy should reprocess the claim after a decision.
Coverage denied
Keep the Notice of Action, review the denial reason and hearing rights, and contact the prescriber for treatment decisions. Do not change the prescribed regimen because of the coverage denial.
Medication needed soon
Tell the pharmacist when the current supply will run out. Medi-Cal Rx says an eligible member may qualify for an emergency fill of up to 14 days while the PA issue is being addressed.
A New PA Requirement Is a Coverage Rule
It does not tell a patient to stop the medication or switch treatments on their own. Any treatment change belongs with the prescriber.
Which Medications Are Affected?
Medi-Cal Rx identifies the following selected drugs and products as requiring an approved PA under the January 1 continuing-care change. The exact dosage form or strength matters.
- Chlorpromazine
- 25 mg/mL and 50 mg/2 mL ampules and vials
- Haloperidol decanoate
- 50 mg/mL and 100 mg/mL ampules.
- Timolol
- 0.25% and 0.5% gel-solution.
- Bimatoprost
- 0.03% eye drops.
- Fluphenazine
- 2.5 mg/mL vial.
- Haloperidol lactate
- 5 mg/mL ampules, vials, and syringes.
- Timolol maleate
- 0.25% and 0.5% eye solution.
- Adhansia XR
- 25 mg, 35 mg, 45 mg, 55 mg, 70 mg, and 85 mg capsules.
Check the Exact Product, Not Just the Generic Name
A PA rule can apply to specific dosage forms or strengths. Ask the pharmacy which exact product triggered the Medi-Cal Rx coverage requirement.
What to Prepare Before the Next Refill
Patients do not write the clinical PA themselves, but having the right information ready can reduce back-and-forth between the pharmacy and prescriber.
01. What is the exact medication, strength, dosage form, and current set of directions?
02. How much medication remains, and when is the current supply expected to run out?
03. Who is the current prescriber, and does the pharmacy have the correct contact information?
04. Has a PA already been submitted, and is there a case or status update available?
05. Has the prescriber discussed covered alternatives or documented why they are not clinically appropriate?
06. Has Medi-Cal Rx issued a denial or Notice of Action that needs to be reviewed?
If the medication was already being used before January 1, do not assume the historical claim record is enough for approval. The new policy specifically says that continuation of therapy alone does not establish medical necessity.
What “Medical Necessity” Means for These New PAs
Medi-Cal Rx continues to prefer drugs and products listed on its Contract Drugs Lists before approving a PA-required alternative. Providers should consider covered therapies that may not require a PA.
If a covered alternative is not clinically appropriate, the provider can submit a PA establishing medical necessity. Medi-Cal Rx says the request should include which drugs or products were tried or considered and why those options do not meet the member’s needs.
- Covered alternative considered
- The provider reviews whether a covered option without PA is clinically appropriate.
- Prior use alone
- Being stable on or having used the medication previously is not enough by itself for approval.
- Why it does not fit
- If an alternative is not appropriate, the PA should explain the clinical reason.
- Clinical documentation
- The prescriber or pharmacy provider supplies the clinical information required for Medi-Cal Rx review.
The Patient Should Not Invent the Clinical Justification
Keep an accurate medication history and tell the prescriber what you have actually used or experienced. The provider is responsible for the clinical PA documentation.
If the PA Is Pending, Urgent, or Denied
Medi-Cal Rx states that PA requests are generally reviewed within 24 hours. A review period does not guarantee approval, and missing information can still require follow-up.
If a drug or product needs approval but is needed right away, Medi-Cal Rx advises members to speak with the pharmacist because an eligible member may qualify for an emergency fill of up to a 14-day supply.
- PA pending
- Ask whether Medi-Cal Rx has received the request and whether additional information is still needed.
- Notice of Action
- Keep the denial notice and review the stated reason and State Hearing rights.
- Medication needed now
- Ask the pharmacist whether an emergency fill is available for the prescription and situation.
- Member support
- Medi-Cal Rx Customer Service is available at 1-800-977-2273, 24 hours a day.
Medi-Cal members who receive a Notice of Action denying coverage generally have 90 days from the notice date to request a State Hearing. For members taking one of the affected drugs on or before January 1, 2026, a request made within 10 days of the Notice of Action may allow continued coverage while the hearing is pending under specified conditions.
Emergency Fill Does Not Guarantee Final Approval
A short emergency supply can help address an immediate access problem, but the PA still needs to be reviewed and approved for ongoing coverage.
Find Out Which Step Is Still Missing
Fireside Pharmacy can help explain the prescription details, claim message, refill timing, PA status, transfer, pickup, or delivery while the prescriber handles clinical documentation.
A January Prior-Authorization Checklist
Use this list before the next fill so the pharmacy and prescriber are not starting from incomplete information.
01. Confirm the exact medication, strength, dosage form, and directions.
02. Verify the prescribing clinician and current contact information.
03. Keep any Notice of Action or claim information together with the medication record.
04. Count the current supply and note the date it is expected to run out.
05. Ask whether a PA has been submitted and whether Medi-Cal Rx needs additional information.
06. If the medication is needed immediately, ask the pharmacist whether an emergency fill may be available.
Frequently Asked Questions
Why does my medication suddenly need prior authorization in January 2026?
Medi-Cal Rx removed selected products from its continuing-care policy effective January 1, 2026. Those products now require an approved PA demonstrating medical necessity.
Is staying on the same medication enough to get the PA approved?
No. Medi-Cal Rx specifically states that continuation of therapy by itself is not enough justification for approval. The provider may need to document alternatives that were tried or considered and why they are not clinically appropriate.
How long does Medi-Cal Rx take to review a PA?
Medi-Cal Rx tells members that PA requests are generally reviewed within 24 hours. Missing information or additional review can still affect the final timing and outcome.
Can I get a short emergency supply while the PA is being worked on?
Possibly. Medi-Cal Rx says an eligible member who needs a PA-required drug or product right away may qualify for an emergency fill of up to a 14-day supply. Ask the pharmacist whether the prescription and situation qualify.
What can I do if Medi-Cal Rx denies the PA?
Keep the Notice of Action and follow the State Hearing instructions. Members generally have 90 days from the notice date to request a hearing, while a shorter 10-day timing rule may matter for certain members seeking continued coverage during the hearing process.
Prepare the Refill Before the Current Supply Is Gone
Use the form above to request a call about prescription details, refill timing, claim messages, PA status, transfer, pickup, or delivery.
