The California Department of Health Care Services (DHCS) has released a notice of upcoming changes to Medi-Cal Rx as part of the 2025-26 state budget. The new rules will be phased in over the coming months, beginning with an update to the coordination of benefits (COB) claims process for Medicare members on November 1, 2025.

Effective November 1, DHCS will adjust how pharmacy claims involving both Medi-Cal and Medicare (known as dual eligible) are submitted and adjudicated to streamline processing. Under the updated rules, pharmacies must submit COB claims with specific NCPDP field codes to ensure Medi-Cal Rx receives the correct payment status and addresses eligibility and payer accuracy

Additional changes effective January 1, 2026, include:

• COVID‑19 Tests: Over-the-counter COVID‑19 antigen tests will require prior authorization (PA) for all Medi-Cal members.
• Weight Loss Drugs: Medications used solely for weight loss or related indications will be removed from Medi-Cal Rx coverage, with patients likely having to pay out of pocket.
• Revisions to OTC coverage for Adults (21+): Reimbursement policies will change for certain OTC products, including prenatal vitamins, multivitamin combinations, single-ingredient vitamins, first- and second-generation antihistamines, and dry eye treatments.
• Continuation of Care Exceptions Removed: Claims receiving coverage under previous continuation of care exceptions (e.g., for drugs listed on the Medi-Cal Rx Contract Drugs List) will no longer be accepted.
• Therapeutic Alternatives Required: Use of certain non-covered drugs will now require prescribing therapeutically equivalent alternatives listed in the Medi-Cal Rx Contract Drugs List before reimbursement is possible.

DHCS frames these changes as necessary to “reduce pharmacy spending, improve program integrity, and ensure continued, equitable access.”

The California Medical Association (CMA) will closely monitor the rollout of these updates to ensure they don’t inadvertently hinder patient access. For more information, practitioners can contact the Medi-Cal Rx Customer Service Center at (800) 977-2273 (available 24/7) or email MediCalRxEducationOutreach@primetherapeutics.com.