The California Department of Health Care Services (DHCS) has issued a 90-day notice announcing upcoming Medi-Cal Rx coverage changes that take effect January 1, 2026. The updates – authorized as part of the 2025-26 state budget – will limit reimbursement for select medications and over-the-counter (OTC) products and expand prior authorization requirements for certain therapies.

Key Updates

COVID-19 Antigen Tests: All OTC COVID-19 antigen tests will require prior authorization unless prescribed by a California Children’s Services (CCS) Paneled Provider for a pediatric patient under age 21. Pharmacy claims for these tests may be approved on a case-by-case basis with medical justification demonstrating the need for suspected COVID-19 exposure or infection. Prior authorizations apply as one-time overrides and cannot be renewed. A new prior authorization is required for each claim. Additionally, approvals are limited to four tests per patient per month.

GLP-1 Drugs: Weight Loss Drugs: GLP-1 receptor agonists prescribed for weight loss or weight-related indications will no longer be covered under Medi-Cal Rx. Coverage will continue for GLP-1 drugs used to treat type 2 diabetes or other non-weight-loss indications with an appropriate ICD-10 code.

Continuation of Care Policies: Drugs currently approved under “continuation of care” exceptions will require a new prior authorization showing medical necessity. Before coverage is granted, prescribers must first try a therapeutic alternative listed on the Medi-Cal Rx Covered Drugs List. The following drugs will be affected: chlorpromazine, fluphenazine, haloperidol (various forms), timolol (gel and solution), bimatoprost, and Adhansia XR (methylphenidate). This policy applies to all Medi-Cal members.

Select OTC Products: DHCS is also revising Medi-Cal Rx coverage policies for several over-the-counter products for Medi-Cal patients 21 years of age and older. Beginning January 1, 2026, multivitamin combination products will no longer be covered. Single-ingredient vitamins and dry-eye treatments will require prior authorization to demonstrate medical necessity, while coverage of first- and second-generation antihistamines will be restricted to generic formulations. Additionally, OTC prenatal vitamins will be limited to use during pregnancy or lactation for Medi-Cal patients between ages 10 and 60. These restrictions do not apply to prescriptions written by CCS Paneled Providers for a pediatric patient under age 21.

Implementation and Support

DHCS is framing these changes as part of a broader effort to control pharmacy costs while ensuring continued access to medically necessary treatments.

Providers with questions can contact the Medi-Cal Rx Customer Service Center at (800) 977-2273 (available 24/7) or email MediCalRxEducationOutreach@primetherapeutics.com for more information.

The California Medical Association (CMA) will continue monitoring the rollout to ensure that patient access and continuity of care are not adversely affected by the new coverage restrictions.