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California Prior Authorization Requirements

Medicaid FFS • Medi-CalMedicare AdvantagePart DMedicare TraditionalMedicaid MCO • Medi-CalDual-EligibleCommercial (employer / fully-insured)Medi-Cal Rx (CA pharmacy carve-out)Commercial — Marketplace QHP

PA required

56%

1,150 verified rules

Verified Jun 8, 2026

Service category PA

All programs combined
Durable Medical Equipment
9/10Conditional
Home Health
8/10Conditional
Mental Health — Inpatient
8/10Conditional
Outpatient Surgery
8/10Conditional
Inpatient Hospital
8/10Conditional
Skilled Nursing Facility
8/10Conditional
Occupational Therapy
7/10Conditional
Physical Therapy
7/10Conditional
Substance Use Treatment
7/10Conditional
Ambulance Transport
7/10Conditional
Speech Therapy
7/10Conditional
Diagnostic Imaging
7/10Conditional
advanced_imaging
7/10Conditional
Specialty Drugs
3/10Conditional
Laboratory
0/10No PA

Drug class PA

Part D federal protections flagged
Oral OncologyFed. Protected
19/22Conditional
ADHD Stimulants
15/17Conditional
Specialty Biologics
13/14Conditional
pulmonary_arterial_hypertension
12/12Full PA
growth_hormone
12/12Full PA
tnf_inhibitors
11/12Conditional
ms_disease_modifying
11/11Full PA
glp1_agonists
11/11Full PA
asthma_copd_biologics
11/11Full PA
migraine_cgrp
11/12Conditional
hepatitis_c_daa
11/12Conditional
il_inhibitors_biologics
10/11Conditional
opioid_analgesics
10/12Conditional
hereditary_angioedema
10/11Conditional
jak_inhibitors
10/11Conditional
testosterone_androgens
10/12Conditional
Hepatitis C
9/10Conditional
pcsk9_inhibitors
9/12Conditional
atypical_antipsychotics
9/12Conditional
antifungals_systemic
9/11Conditional
anticonvulsants
8/12Conditional
inhaled_respiratory
8/12Conditional
Rare Disease / Orphan
7/8Conditional
Immunosuppressants
7/10Conditional
other_antidepressants
7/11Conditional
Controlled — Schedule III–V
6/7Conditional
Controlled — Schedule II
6/7Conditional
skeletal_muscle_relaxants
6/10Conditional
opioid_use_disorder
6/12Conditional
anxiolytics_benzodiazepines
6/12Conditional
antiplatelets
6/12Conditional
Brand (No Generic)
5/6Conditional
Diabetes — Non-Insulin
5/6Conditional
Biosimilars
5/6Conditional
Brand (Generic Available)
5/6Conditional
Diabetes — Insulin
5/6Conditional
Specialty Non-Biologic
5/6Conditional
oral_retinoids
5/10Conditional
nsaids
5/11Conditional
ppi_acid_reducers
5/12Conditional
GLP-1 (Weight Loss)
4/9Conditional
AntipsychoticsFed. Protected
4/7Conditional
insulins
4/12Conditional
hemophilia_factors
4/4Full PA
dermatology_biologics
4/4Full PA
wakefulness_agents
4/4Full PA
cystic_fibrosis_modulators
4/4Full PA
glp1_diabetes
3/3Full PA
Antidepressants
3/6Conditional
anticoagulants_doac
3/12Conditional
overactive_bladder
3/12Conditional
vmat2_inhibitors
3/3Full PA
enzyme_replacement
3/3Full PA
dpp4_inhibitors
3/11Conditional
oxybate_salts
3/3Full PA
sedative_hypnotics
3/10Conditional
weight_loss_agents
3/4Conditional
oncology_supportive
3/3Full PA
antihistamines
3/9Conditional
dalfampridine
3/3Full PA
immunoglobulins
3/3Full PA
erectile_dysfunction
2/3Conditional
HIV AntiretroviralsFed. Protected
2/17Conditional
sglt2_inhibitors
2/10Conditional
other_antidiabetics
2/11Conditional
statins
2/12Conditional
hematopoietic_growth_factors
2/2Full PA
arbs
2/10Conditional
calcium_channel_blockers
2/10Conditional
infertility_agents
2/2Full PA
antiparkinson_agents
2/2Full PA
otc_covid_antigen_test
1/1Full PA
otc_cough_cold
1/1Full PA
hormone_replacement
1/1Full PA
inhaled_corticosteroid
1/1Full PA
ophthalmic_steroid
1/1Full PA
opioid_new_start
1/1Full PA
opioid_chronic_therapy
1/1Full PA
benzodiazepines
1/1Full PA
buprenorphine_oud
1/1Full PA
insulin_prandial
1/1Full PA
insulin_basal
1/1Full PA
hormone_replacement_contraceptives
1/1Full PA
triptans
1/11Conditional
antibacterials_systemic
1/1Full PA
sexual_dysfunction_agents
1/1Full PA
cns_miscellaneous
1/1Full PA
thyroid_agents
1/3Conditional
antiparasitics
1/1Full PA
immunological_immunomodulators
1/1Full PA
roflumilast
1/3Conditional
pulmonary_fibrosis
1/1Full PA
electrolytes_vitamins
1/1Full PA
osteoporosis_anabolics
1/1Full PA
metabolic_bone_other
1/1Full PA
antivirals_other
1/2Conditional
gi_bowel_motility
1/1Full PA
ophthalmic_anti_inflammatory_anti_infective
1/1Full PA
ophthalmic_dry_eye_misc
1/1Full PA
respiratory_allergy_cough_cold
1/1Full PA
topical_steroids
1/4Conditional
bisphosphonates
1/11Conditional
sleep_and_wakefulness_agents
1/1Full PA
ssri_antidepressants
1/10Conditional
other_lipid_agents
1/1Full PA
antibiotics_general
1/1Full PA
allergen_immunotherapy
1/1Full PA
continuous_glucose_monitors
1/1Full PA
estrogens_hrt
1/1Full PA
diuretics
1/3Conditional
gnrh_oncology_hormonal
1/1Full PA
cough_cold
1/1Full PA
ophthalmic_agents
1/1Full PA
gi_other
1/1Full PA
transplant_immunosuppressants
1/1Full PA
other_cardiovascular
1/1Full PA
parkinsons_agents
1/1Full PA
cannabidiol
1/2Conditional
miscellaneous_specialty
1/1Full PA
il1_other_immunomodulators
1/1Full PA
oncology_hormonal
1/2Conditional
viscosupplements
1/1Full PA
antilipemics_acl_inhibitors
1/1Full PA
als_agents
1/1Full PA
cortisol_synthesis_inhibitors
1/1Full PA
movement_disorders
1/1Full PA
carnitine_deficiency_agents
1/1Full PA
endometriosis_agents
1/1Full PA
calcium_regulators_misc
1/1Full PA
botulinum_toxins
1/1Full PA
hereditary_tyrosinemia
1/1Full PA
acromegaly_agents
1/1Full PA
immunologic_misc
1/1Full PA
growth_improvement_agents
1/1Full PA
sickle_cell_disease
1/1Full PA
alpha1_antitrypsin_deficiency
1/1Full PA
platelet_disorders
1/1Full PA
immunomodulators
1/1Full PA
multiple_sclerosis_agents
1/1Full PA
central_precocious_puberty
1/1Full PA
myasthenia_gravis_agents
1/1Full PA
chelating_agents
1/1Full PA
vasopressins
1/1Full PA
narcolepsy_cataplexy_agents
1/1Full PA
calcium_receptor_agonists
1/1Full PA
polyneuropathy_agents
1/1Full PA
uterine_fibroids
1/1Full PA
paroxysmal_nocturnal_hemoglobinuria
1/1Full PA
fertility_regulators
1/1Full PA
autoimmune_physician_administered
1/1Full PA
dermatology_antipsoriatics
1/1Full PA
urea_cycle_disorder
1/1Full PA
ophthalmic_anti_vegf
1/2Conditional
pulmonary_fibrosis_agents
1/1Full PA
bleeding_disorders_agents
1/1Full PA
pde4_inhibitors_inflammatory
1/1Full PA
antibiotics_misc
1/1Full PA
calcimimetics
1/1Full PA
cough_cold_allergy
1/1Full PA
dermatology_topical_other
1/1Full PA
metabolic_disorder_agents
1/1Full PA
hepatitis_b_agents
1/1Full PA
immunosuppressants_misc
1/1Full PA
hematopoietic_esa
1/1Full PA
neuro_psych_misc
1/1Full PA
ovulation_stimulants
1/1Full PA
il_inhibitors_ibd
1/1Full PA
ophthalmic_anti_inflammatory
1/1Full PA
ssri_snri_other_antidepressants
1/1Full PA
cardiovascular_agents
1/1Full PA
dermatology_topical_and_biologics
1/1Full PA
diabetes_supplies_glucose_monitoring
1/1Full PA
opioid_partial_agonists
1/1Full PA
hepatitis_b
1/1Full PA
migraine_misc
1/1Full PA
ibs_constipation
1/1Full PA
ibs_diarrhea
1/1Full PA
pancreatic_enzymes
1/1Full PA
dry_eye_disease
1/1Full PA
Compounded Medications
0/6No PA
Opioid Treatment (MOUD)
0/6No PA
vaccines_zoster
0/1No PA
hiv_pep
0/1No PA
cannabinoid_antiemetics
0/2No PA
anaphylaxis_epinephrine
0/1No PA
antimyasthenic_agents
0/1No PA
antimycobacterials_tb
0/1No PA
vaccines
0/2No PA
inflammatory_bowel_disease
0/2No PA
bipolar_agents_lithium
0/1No PA
antigout_agents
0/1No PA
bph_agents
0/2No PA
otic_agents
0/4No PA
leukotriene_modifiers
0/10No PA
antidementia_alzheimers
0/1No PA
dental_oral_agents
0/1No PA
oral_corticosteroids
0/1No PA
snri_antidepressants
0/3No PA
ace_inhibitors
0/10No PA
contraceptives
0/3No PA
alzheimers_agents
0/2No PA
beta_blockers
0/10No PA
dental_products
0/1No PA
feminine_products
0/1No PA
hepatitis_b_antivirals
0/1No PA
nutritional_dietary
0/1No PA
smoking_cessation
0/1No PA
vitamins
0/2No PA
fluoroquinolones
0/1No PA
anthelmintics
0/2No PA
antilipemics_fibrates
0/1No PA
digitalis_glycosides
0/1No PA
antiparkinsonian_agents
0/1No PA
antitubercular_agents
0/1No PA
anti_infectives_misc
0/1No PA
gout_agents
0/1No PA
aldosterone_antagonists
0/1No PA
direct_renin_inhibitors
0/1No PA
alcohol_deterrents
0/1No PA
fibromyalgia_agents
0/1No PA
nitrates
0/1No PA
antilipemics_cholesterol_absorption
0/1No PA
antimalarials
0/2No PA
alpha_blockers
0/1No PA
salicylates
0/1No PA
antilipemics_bile_acid_resins
0/1No PA
cardiovascular_misc
0/1No PA
non_opioid_analgesics
0/2No PA
macrolides
0/1No PA
antidementia_agents
0/1No PA
antibacterials_misc
0/1No PA
antivirals_systemic
0/1No PA
tetracyclines
0/1No PA
antilipemics_misc
0/1No PA
postherpetic_neuralgia
0/1No PA
antiarrhythmics
0/2No PA
cephalosporins
0/1No PA
mood_stabilizers
0/1No PA
gi_anticholinergics
0/1No PA
ulcer_therapy_combinations
0/1No PA
h2_receptor_antagonists
0/1No PA
cns_misc
0/1No PA
vaginal_anti_infectives
0/2No PA
ophthalmic_anti_inflammatories
0/1No PA
diabetic_supplies
0/1No PA
ophthalmic_antiallergics
0/1No PA
anaphylaxis_treatment_agents
0/1No PA
migraine_ergotamines
0/1No PA
psychotherapeutic_misc
0/1No PA
menopausal_symptom_agents
0/1No PA
gastrointestinal_misc
0/1No PA
ophthalmic_antiglaucoma_combinations
0/1No PA
dmards
0/1No PA
nutritional_misc
0/1No PA
glucose_elevating_agents
0/1No PA
phosphate_binders
0/1No PA
ophthalmic_anti_infectives
0/1No PA
dermatology_acne
0/1No PA
vitamin_d_analogs
0/1No PA
rectal_corticosteroids
0/1No PA
ophthalmic_carbonic_anhydrase_inhibitors
0/1No PA
mast_cell_stabilizers
0/1No PA
benign_prostatic_hyperplasia
0/1No PA
allergenic_extracts
0/1No PA
ophthalmic_antiglaucoma_beta_blockers
0/1No PA
smoking_deterrents
0/1No PA
endocrine_metabolic_misc
0/1No PA
gi_antispasmodics
0/1No PA
genitourinary_misc
0/1No PA
ophthalmic_sympathomimetics
0/1No PA
dermatology_antiseborrheics
0/1No PA
musculoskeletal_therapy_agents
0/1No PA
glucocorticoids
0/1No PA
ophthalmic_anti_infective_anti_inflammatory
0/1No PA
xanthines
0/1No PA
prenatal_vitamins
0/1No PA
dermatology_antibiotics
0/1No PA
ophthalmic_rho_kinase_inhibitors
0/1No PA
electrolytes
0/1No PA
cold_cough
0/1No PA
dermatology_scabicides_pediculicides
0/1No PA
progestins
0/1No PA
antidiarrheals
0/1No PA
ophthalmic_prostaglandins
0/1No PA
dermatology_misc
0/1No PA
laxatives
0/2No PA
dermatology_rosacea
0/1No PA
ophthalmic_misc
0/1No PA
dermatology_antifungals
0/1No PA
respiratory_misc
0/1No PA
dermatology_local_anesthetics
0/1No PA
ophthalmic_other
0/1No PA
dermatology_actinic_keratosis
0/1No PA
dermatology_antipruritic
0/1No PA
dermatology_wound_care
0/1No PA
mouth_throat_dental_agents
0/1No PA
anticoagulants_heparins
0/1No PA
antianginal_nitrates
0/1No PA
antiemetics
0/1No PA
anticoagulants_warfarin
0/1No PA
antimycobacterial
0/1No PA
serms
0/1No PA
hematinics_other
0/1No PA
antidiarrheal_probiotic
0/1No PA
other_antihypertensives
0/1No PA
opioid_reversal_antidotes
0/1No PA
corticosteroids_systemic
0/1No PA
antipsoriatics_topical
0/1No PA
other_antihyperlipidemics
0/1No PA
antimyasthenic_cholinergic
0/1No PA
cardiotonics
0/1No PA
digestive_enzymes
0/1No PA
arni_sacubitril
0/1No PA
vasopressin_desmopressin
0/1No PA
interstitial_cystitis
0/1No PA
hemostatics
0/1No PA
estrogens_progestins
0/1No PA
fibromyalgia_snri
0/1No PA
vitamins_minerals
0/1No PA
anorectal_rectal
0/1No PA
pharmaceutical_adjuvants
0/1No PA
ophthalmic_glaucoma
0/2No PA
topical_anti_infectives
0/1No PA
nutritional_metabolic
0/1No PA
mouth_throat_dental
0/1No PA
vaccines_toxoids
0/1No PA
smoking_alcohol_deterrents
0/1No PA
vasopressors_anaphylaxis
0/1No PA
medical_supplies_devices
0/1No PA
esketamine
0/1No PA
methadone
0/1No PA
heart_failure_agents
0/1No PA
antilipemics_omega3
0/1No PA
potassium_removing_agents
0/1No PA

PA type breakdown

clinical_criteria
448
Conditional
111
Full PA
67
quantity_limit
8

Federal protected classes requiring PA

Oral OncologyPA required
AntidepressantsPA required
AntipsychoticsPA required
ImmunosuppressantsPA required

State flags

Medicaid expansion state
WISeR pilot (high data quality)
FFS-dominant (minimal MCO)

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