Medi-Cal covers pharmacy benefits which includes medications (legend and over-the- counter (OTC)), disposable outpatient medical supplies, and enteral formula for members through the Medi-Cal Rx program. Reimbursement for pharmacy benefits covered under the Medi-Cal Rx program may include an ingredient cost, dispensing fee, and administration fee and are specific to the claim and the member’s eligibility. Additionally, Medi-Cal covers physician administered drugs (PADs), medical supplies, and incontinence supplies billed on a medical claim using a Healthcare Common Procedure Coding System (HCPCS) code. Pricing for pharmacy benefits billed on a medical claim are based on an individual cost per unit and the overall claim will include a percentage mark up for the pharmacy provider.

Effective for dates of service on or after April 1, 2017, reimbursement for any outpatient drug covered under the Medi-Cal program¹ is the lowest of either of the following:

• Actual Acquisition Cost (AAC) plus a professional dispensing fee. The AAC is equal to the lowest of the following:
  • National Drug Acquisition Cost (NADAC), or when no NADAC is available, the wholesale acquisition cost (WAC),
  • Maximum allowable ingredient cost (MAIC),
  • Federal Upper Limit (FUL),
• The pharmacy’s usual and customary charge.

Note: Additional product cost due to special packaging is not reimbursed (for example, unit of use, modified unit dose or unit dose).

Medi-Cal Rx Covered Medications

Medi-Cal Rx legend and OTC medications are reimbursed per unit of cost of the medication multiplied by the number of units of medication plus a dispensing fee per claim.

• Example: (Amoxicillin 500mg at $1.00 per capsule) times 30 capsules equals $30.00 plus a dispensing fee

Medi-Cal Rx disposable outpatient medical supplies and enteral formula are reimbursed per unit of supply or formula (each, milliliter, or gram) multiplied by the number of units plus a 23 percent markup.

• Example: (Pen needles at $1.00 per each) times 30 needles equals $30.00 plus a 23 percent markup ($6.90)
• The amount reimbursed to pharmacy providers for enteral nutrition formula is the estimated acquisition cost (EAC) per unit listed in the contracted list, plus a 23 percent markup. For most outpatient medical supplies, Assembly Bill 97 (2011)² still impacts enteral nutrition claims; where a 10 percent reduction applies to each paid claim, reducing the overall reimbursement to pharmacy providers.  

Please refer to the Medi-Cal Rx provider manual using the following links for specific reimbursement methodology information:

Medi-Cal Rx Pharmacy Program Category	Pharmacy Rate August 2026 Rate Information
Legend and Non-Legend Drugs Ingredient Cost	Sections 4.6.1 and 4.6.3 Medi-Cal Rx Provider Manual
Professional Dispensing Fee	Section 4.6.2 Medi-Cal Rx Provider Manual
Compound Prescriptions	Section 4.6.7 Medi-Cal Rx Provider Manual
Blood Factor	Section 4.6.16 Medi-Cal Rx Provider Manual
340B Pharmacy claims	Section 4.6.5 Medi-Cal Rx Provider Manual
Vaccine Administration Fee	Section 4.6.18 Medi-Cal Rx Provider Manual
Vaccines for Children Program	Section 15.9.1 Medi-Cal Rx Provider Manual

Medi-Cal Rx Professional Dispensing Fee

Medi-Cal Rx utilizes a two-tiered professional dispensing fee based on a pharmacy’s net (both Medicaid and non-Medicaid) annual claim volume as follows:

• Less than 90,000 net claims per year = $13.20
• 90,000 or more net claims per year = $10.05

The dispensing fee is added to each claim as a reimbursement to the pharmacy provider.

Medi-Rx Drug Lookup Tool

The Drug Lookup Tool is a tool on the Medi-Cal Rx website and allows anyone to search a medication’s National Drug Code (NDC) or drug name in the Medi-Cal Rx program. The tool will be enhanced to show reimbursement per unit and will continue to allow users to search for covered medications, identify which medications need prior authorization, identify if the drug has a Code 1 restriction, whether or not the drug is a generic or brand name, and the specific National Drug Codes (NDCs). The follow information is listed on the Drug Look Up Tool:

• Label Name (This will be the brand or generic name)
• NDC (specific NDCs for the brand and the generic)
• Drug Type (Brand or Generic)
• Prior Authorization (states whether or not a drug needs a prior authorization and also has a link to “Medi-Cal Options for PA Submission Guide”.)
• Code 1 (States whether or not a drug has a Code 1 (specific requirements must be met for a diagnosis or a disease condition) and provides a link to the Contract Drugs List (CDL) where users can then look up the specific Code 1 restriction.)
• (Coming Soon) Price per unit (This is the price per unit of the drug. This amount does not include a dispensing fee or a markup and is based upon most recent First Data Bank pricing information. First Data Bank is the Medi-Cal Rx program’s drug database source.)

Medi-Cal Covered Medical Supplies and Enteral Formula

The Medi-Cal Rx Program covers specific outpatient medical supplies and enteral formula, if listed on a covered or contracted list. Reimbursement for these benefits varies based upon the covered or contract price per unit, gram, or milliliter. Pharmacy providers are reimbursed with a 23 percent markup per claim. The following links on the Medi-Cal Rx website provides a list with pricing information for these benefits:

Pharmacy Benefit	Resource
Contracted Drug and Covered Products Lists	Medi-Cal Rx Contract Drugs List (CDL)
Contracted Enteral Nutrition Products List	Medi-Cal Rx Contracted Enteral Formula List
Covered Medi-Cal Rx Medical Supplies List	Covered Medical Supplies Product Descriptions and Billing Information

Medi-Cal Reimbursed Pharmacy Benefits on a Medical Claim using a HCPCS Code

Medi-Cal covers physician administered drugs (PADs), disposable outpatient medical supplies, and incontinence supplies billed on a medical claim using a Healthcare Common Procedure Coding System (HCPCS) code. Pricing for pharmacy benefits billed on a medical claim are based on an individual cost per unit and the overall claim will include a percentage mark up for the pharmacy provider. Please see the following resources for specific HCPCS code rates for covered pharmacy benefits.

Pharmacy Benefit	Resource
Covered Medi-Cal procedures including PADs	Medi-Cal Rates by Procedure Code
PADs Provider Manual	Physician-administered drugs (PAD) reimbursement methodology
PAD Reimbursement Rates	Medi-Cal Maximum Allowable Reimbursement Rates for PAD
Pharmacist Services Policy and Billing Information	Pharmacist Services
Disposable Outpatient Medical Supplies and Incontinence Supplies Policy, Billing, and Rates Information	Pharmacy Provider Manual | Medi-Cal Providers

Contact DHCS

Questions or comments can be submitted to the Pharmacy Benefits Division mailbox: medi-cal.pharmacybenefits@dhcs.ca.gov

¹ California Welfare and Institutions Code Section 14105.45 

² Assembly Bill 97 Ten Percent Pharmacy Payment Reductions | DHCS