California Medi-Cal Formulary: Contract Drugs List and Exceptions

The Medi-Cal formulary is called the Contract Drugs List (CDL), and it is the statewide list of outpatient prescription drugs the program covers without extra approval steps. If your medication is on the CDL, a pharmacy can generally fill it. If it isn’t, your prescriber can still request coverage through a prior authorization process, though a small number of drug categories are excluded from the program entirely.

Check Whether Your Drug Is on the List

The fastest way to find out is the Medi-Cal Rx web portal, which hosts the current CDL and lets you search by drug name.¹ A match means the drug is covered. The search result also flags any utilization restrictions attached to it, such as quantity limits or step therapy.

If the drug doesn’t appear on the CDL, that isn’t a final no. It means your prescriber has to go through prior authorization before the pharmacy can fill it.

What the Contract Drugs List Is

The California Department of Health Care Services (DHCS) maintains the CDL as the official Medi-Cal formulary.² It typically includes drugs for which California has negotiated a supplemental rebate with the manufacturer. Under federal law, state Medicaid programs must cover all “covered outpatient drugs” from manufacturers that have signed a federal rebate agreement, which is why the list is broad.³ Before DHCS removes a drug from the CDL, it must send providers a 60-day advance notice.

Since January 1, 2022, nearly all outpatient pharmacy services moved to the statewide fee-for-service system now called Medi-Cal Rx, so most beneficiaries use the same CDL whether they are in a managed care plan or traditional Medi-Cal.⁴ Managed care plans may still handle coverage for certain non-drug medical supplies, so check with your plan if what you need isn’t a standard prescription.

Restrictions That Apply Even to Covered Drugs

Being on the CDL does not always mean the drug can be dispensed in any quantity or form. Medi-Cal applies utilization controls meant to track FDA dosing guidelines and clinical standards.

Quantity Limits

A quantity limit caps how much you can receive in a given period. A once-daily medication, for example, is typically limited to a 30-day supply per fill. If you need more, your prescriber has to request prior authorization.

Step Therapy and Dose Optimization

Step therapy requires you to try one or more alternative drugs, usually older or generic options for the same condition, before Medi-Cal will cover a more expensive one. If the first-line drug fails or causes side effects, your prescriber can request the next step. Dose optimization is a related rule aimed at keeping the prescribed dosage and form clinically appropriate and cost-effective. Prescribing outside those parameters also triggers prior authorization.⁵

Categories Medi-Cal Can Exclude

Federal law lets states exclude or restrict certain drug categories regardless of whether the manufacturer has a rebate agreement.³ If your medication falls into one of these categories, it may not be available through Medi-Cal even with a prior authorization request:

Drugs used for anorexia, weight loss, or weight gain
Fertility drugs
Drugs for cosmetic purposes or hair growth
Cough and cold products for symptomatic relief
Prescription vitamins and minerals, except prenatal vitamins and fluoride preparations
Over-the-counter drugs, with limited exceptions such as certain tobacco cessation products for pregnant women
Drugs for sexual or erectile dysfunction, unless prescribed for another FDA-approved condition

Prenatal vitamins are the notable exception within the vitamin category and are covered.

Getting a Non-Formulary Drug Approved

When a drug isn’t on the CDL, or when a covered drug is prescribed in a way that exceeds its listed restrictions, your prescriber submits a Treatment Authorization Request (TAR) to Medi-Cal Rx.⁵ The TAR must include medical documentation showing why the requested drug is necessary for your condition, typically that the alternatives on the CDL would be ineffective, cause harmful side effects, or are otherwise medically inappropriate. TARs can be submitted electronically, by fax, or by mail.

The 24-Hour Response Rule

Federal law requires any Medicaid prior authorization system to respond within 24 hours of receiving a request.³ DHCS has stated Medi-Cal Rx follows this rule, with the reviewer approving, modifying, deferring, or denying each request.⁵

The 72-Hour Emergency Supply

If you need a medication urgently and the prior authorization has not yet been approved, federal law requires the pharmacy to dispense at least a 72-hour emergency supply while authorization is pending. This applies to most covered outpatient drugs, but not to drugs in the federally excludable categories listed above.³ If a pharmacist says they cannot fill a prescription because prior authorization is needed, ask specifically about the emergency supply. This is where many beneficiaries lose access to medication they could legally receive.

If a Request Is Denied

You can appeal a denied TAR by requesting a State Fair Hearing, an independent review by an administrative law judge. You have 90 days from the date the denial notice was mailed to request a hearing. Between 90 and 180 days, a judge may still accept a late filing if you show good cause for the delay.⁶

Two timing details often decide the outcome:

Aid paid pending. If you were already receiving the medication before the denial, you can keep receiving it during the hearing, but only if you file the hearing request within 10 days of the denial notice or before the date the notice says the service will end, whichever is later.⁶
Expedited hearing. If your situation is urgent, you can ask for an expedited hearing. You must explain in writing why the case is urgent, or the request will be denied.

Hearing requests can be made by phone at 1-800-743-8525, by fax to 833-281-0905, online through the California Department of Social Services website, or by mail to the State Hearings Division in Sacramento.⁶ Federal regulations guarantee you the right to review your case file, bring witnesses, present evidence, and cross-examine any witnesses the state presents.⁷

If You Have Both Medicare and Medi-Cal

If you are dually eligible for Medicare and Medi-Cal, your prescription drug coverage works differently. Medicare Part D becomes the primary payer for your outpatient prescriptions, not Medi-Cal, and your drugs are covered through your Part D plan’s formulary rather than the CDL.⁸ Medi-Cal can still help with costs Medicare doesn’t fully pay, including some medications or services the Part D plan doesn’t include. Start with the Part D plan rather than Medi-Cal Rx if you are dually eligible and having trouble getting a drug covered.

Co-Payments

Medi-Cal charges nominal co-payments for some prescriptions, generally a few dollars per fill. Many beneficiary groups are exempt entirely, including children and pregnant women. Under federal Medicaid rules, a pharmacy cannot refuse to fill your prescription if you can’t pay the co-payment, though you may still be billed for the amount owed.⁹

1
Medi-Cal Rx. Contract Drugs List (CDL)
2
Department of Health Care Services. Medi-Cal Rx Contract Drugs List
3
Office of the Law Revision Counsel. 42 USC 1396r-8 Payment for Covered Outpatient Drugs
4
Department of Health Care Services. Medi-Cal Rx Transitioning Medi-Cal Pharmacy Services from Managed Care to FFS FAQs
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Department of Health Care Services. Medi-Cal Rx Prior Authorization and Utilization Management and Related Appeals Processes
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Medi-Cal Rx. State Fair Hearing Request Form
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eCFR. 42 CFR Part 431 Subpart E – Fair Hearings for Applicants and Beneficiaries
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Centers for Medicare & Medicaid Services. Beneficiaries Dually Eligible for Medicare and Medicaid
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Medicaid.gov. Cost Sharing Out of Pocket Costs