Statutes, codes, and regulations
California Code Of Regulations
Title 22 - Social SecurityDivision 3 - Health Care ServicesSubdivision 1 - California Medical Assistance ProgramChapter 3 - Health Care Services
Article 4 - Scope and Duration of Benefits
Section 51313 - Pharmaceutical Services and Prescribed Drugs

Cal. Code Regs. tit. 22 § 51313

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Current through Register 2024 Notice Reg. No. 49, December 6, 2024
Section 51313 - Pharmaceutical Services and Prescribed Drugs
(a) Drugs on the Medi-Cal List of Contract Drugs are covered, subject to limitations specified in this Section and Section 51313.3 when prescribed by a licensed practitioner within the scope of the practitioner's practice as defined by California law.
(b) Drugs shall be furnished in quantities not to exceed a 100 calendar day supply except for sodium fluoride tablets, drops and solutions or when necessary to comply with minimum quantities specified in section 51513.
(c) Drugs not on the Medi-Cal List of Contract Drugs and not excluded in Section 51313.3 are covered subject to prior authorization in accordance with Section 51003.
(1) Authorization may be granted when:
(A) The clinical condition of the patient requires the use of an unlisted drug and listed drugs have been adequately considered or tried and do not meet the medical needs of the patient.
(B) The use of an unlisted drug results in a less expensive treatment than would otherwise occur.
(2) Authorization for prescribed drugs shall be granted for a specific quantity of medication and number of refills, if any, in accordance with the beneficiary's medical need and the chronicity of the condition.
(3) Prescribed drugs dispensed on an emergency basis are exempt from prior authorization. However, any such emergency service shall conform to the definition in section 51056(a) and the provider shall comply with the provisions of section 51056(b).
(4) Authorization for unlabeled use of drugs shall not be granted unless the requested unlabeled use represents reasonable and current prescribing practices. The determination of reasonable and current prescribing practices shall be based on:
(A) Reference to current medical literature.
(B) Consultation with provider organizations, academic and professional specialists.
(d) Drugs listed under Sections 51510(c), 51510.1(b), 51510.2(b)(4), .3(b)(4) and 51511(c) are covered for the treatment of skilled nursing facility or intermediate care facility inpatients (including developmentally disabled, developmentally disabled/habilitative, and developmentally disabled/nursing), subject to the requirements of subdivisions (a), (b) and (c) except for drugs which are included in the daily facility rate as specified in Sections 51510, 51510.1, 51510.2, 51510.3 and 51511.
(e) Drugs for the treatment of hospital cute care or hospital extended care inpatients, including discharge medications, are covered as encompassed in the formulary of the hospital and are not subject to the limitations of (a) through (c) above.
(1) The quantities furnished as discharge medications shall not exceed a 10 days supply.
(2) The charges shall be incorporated in the hospital's claim for inpatient services.
(f) Drugs administered for chronic outpatient hemodialysis in renal dialysis centers and community hemodialysis units are covered, but are payable only when included in the all-inclusive rate set forth in section 51509.2.
(g) Drugs included under Prudent Purchase of Drug contracts, as set forth in section 51513.6 are covered subject to the conditions set forth in section 51513.6 and the other provisions of this section.

Cal. Code Regs. Tit. 22, § 51313

1. Amendment of subsections (a) and (c) filed 9-16-85 as an emergency; effective upon filing (Register 85, No. 39). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 1-14-86. For prior history, see Register 83, No. 44.
2. Certificate of Compliance including amendment of subsections (a) and (c)(2) transmitted to OAL 1-2-86 and filed 2-3-86 (Register 86, No. 7).
3. Change without regulatory effect of NOTE (Register 86, No. 49).
4. Certificate of Compliance including new subsection (c)(4) transmitted to OAL 4-14-88 and filed 5-16-88 (Register 88, No. 21).
5. Amendment of subsection (d) filed 5-8-91; operative 5-8-91 (Register 91, No. 24).
6. Amendment of subsections (a), (c) and (d) and new subsection (h) filed 5-22-91 as an emergency pursuant to Statutes of 1990, chapter 456, section 36, p. 1658-1659; operative 5-22-91 (Register 91, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-19-91 or emergency language will be repealed by operation of law on the following day.
7. Amendment of subsections (a), (c) and (d) and new subsection (h) refiled 9-19-91 as an emergency; operative 9-20-91 (Register 92, No. 4). A Certificate of Compliance must be transmitted to OAL 1-20-92 or emergency language will be repealed by operation of law on the following day.
8. Amendment of subsections (a), (c) and (d) refiled 1-23-92 as an emergency; operative 1-17-92 (Register 92, No. 25). A Certificate of Compliance must be transmitted to OAL 5-22-92 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 1-23-92 order including amendment of NOTE transmitted to OAL 5-22-92 and filed 7-6-92 (Register 92, No. 28).
10. Repealer of subsection (h) and amendment of NOTE filed 1-9-95; operative 3-1-95 (Register 95, No. 2).
11. Editorial correction of subsection (g) (Register 95, No. 25).

Note: Authority cited: Sections 10725, 14105, 14105.44 and 14124.5, Welfare and Institutions Code; Chapter 328, Section 57, and Chapter 1594, Section 87, Statutes of 1982. Reference: Sections 14053, 14105.3, 14105.35, 14105.44, 14132, 14133 and 14133.1, Welfare and Institutions Code.

1. Amendment of subsections (a) and (c) filed 9-16-85 as an emergency; effective upon filing (Register 85, No. 39). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 1-14-86. For prior history, see Register 83, No. 44.
2. Certificate of Compliance including amendment of subsections (a) and (c)(2) transmitted to OAL 1-2-86 and filed 2-3-86 (Register 86, No. 7).
3. Change without regulatory effect of NOTE (Register 86, No. 49).
4. Certificate of Compliance including new subsection (c)(4) transmitted to OAL 4-14-88 and filed 5-16-88 (Register 88, No. 21).
5. Amendment of subsection (d) filed 5-8-91; operative 5-8-91 (Register 91, No. 24).
6. Amendment of subsections (a), (c) and (d) and new subsection (h) filed 5-22-91 as an emergency pursuant to Statutes of 1990, chapter 456, section 36, p. 1658-1659; operative 5-22-91 (Register 91, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-19-91 or emergency language will be repealed by operation of law on the following day.
7. Amendment of subsections (a), (c) and (d) and new subsection (h) refiled 9-19-91 as an emergency; operative 9-20-91 (Register 92, No. 4). A Certificate of Compliance must be transmitted to OAL 1-20-92 or emergency language will be repealed by operation of law on the following day.
8. Amendment of subsections (a), (c) and (d) refiled 1-23-92 as an emergency; operative 1-17-92 (Register 92, No. 25). A Certificate of Compliance must be transmitted to OAL 5-22-92 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 1-23-92 order including amendment of Note transmitted to OAL 5-22-92 and filed 7-6-92 (Register 92, No. 28).
10. Repealer of subsection (h) and amendment of Note filed 1-9-95; operative 3-1-95 (Register 95, No. 2).
11. Editorial correction of subsection (g) (Register 95, No. 25).