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CA

California Prior Authorization Requirements

Medicaid FFS • Medi-CalMedicaid MCO • Medi-CalMedicare AdvantageDual-EligiblePart DMedicare TraditionalCommercial (employer / fully-insured)Medi-Cal Rx (CA pharmacy carve-out)

PA required

70%

319 verified rules

Verified May 22, 2026

Service category PA

All programs combined
Durable Medical Equipment
9/10Conditional
Home Health
8/10Conditional
Outpatient Surgery
8/10Conditional
Inpatient Hospital
8/10Conditional
Skilled Nursing Facility
8/10Conditional
Mental Health — Inpatient
8/10Conditional
Substance Use Treatment
7/10Conditional
Ambulance Transport
7/10Conditional
Speech Therapy
7/10Conditional
Physical Therapy
7/10Conditional
Occupational 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
Specialty Biologics
13/14Conditional
Oral Oncology
11/14Conditional
Hepatitis C
9/10Conditional
Rare Disease / Orphan
7/8Conditional
Immunosuppressants
6/9Conditional
Controlled — Schedule II
6/7Conditional
Controlled — Schedule III–V
6/7Conditional
ADHD Stimulants
5/6Conditional
Biosimilars
5/6Conditional
Brand (No Generic)
5/6Conditional
Brand (Generic Available)
5/6Conditional
Diabetes — Insulin
5/6Conditional
Diabetes — Non-Insulin
5/6Conditional
Specialty Non-Biologic
5/6Conditional
GLP-1 (Weight Loss)
4/9Conditional
Antipsychotics
4/7Conditional
glp1_diabetes
3/3Full PA
HIV AntiretroviralsFed. Protected
3/6Conditional
AntidepressantsFed. Protected
3/6Conditional
anticoagulants_doac
1/1Full PA
benzodiazepines
1/1Full PA
buprenorphine_oud
1/1Full PA
hormone_replacement
1/1Full PA
inhaled_corticosteroid
1/1Full PA
insulin_basal
1/1Full PA
insulin_prandial
1/1Full PA
opioid_chronic_therapy
1/1Full PA
opioid_new_start
1/1Full PA
otc_cough_cold
1/1Full PA
otc_covid_antigen_test
1/1Full PA
ophthalmic_steroid
1/1Full PA
Compounded Medications
0/6No PA
Opioid Treatment (MOUD)
0/6No PA
erectile_dysfunction
0/1No PA
hiv_pep
0/1No PA
vaccines_zoster
0/1No PA

PA type breakdown

Conditional
114
Full PA
69
clinical_criteria
26
quantity_limit
8

Federal protected classes requiring PA

HIV AntiretroviralsPA required
ImmunosuppressantsPA required
AntidepressantsPA required
AntipsychoticsPA required
Oral OncologyPA required

State flags

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

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