California prescribers use DHCS 6505 to request prior authorization from Medi-Cal Rx for an enteral nutrition product. The five-page form covers the member, prescriber, product with 11-digit NDC, dosing and therapy length, prior enteral products tried, diagnoses with ICD-10-CM codes, and daily caloric requirements, with extra justification when calories exceed the form's limits for tube-fed or oral patients.
The prescriber completes the form and signs the attestation; the prescriber type checkboxes are physician, nurse practitioner, physician assistant and other. A requestor section is available when someone other than the prescriber submits it.
Download the current version from the source each time; forms change without notice.
Medi-Cal Rx Enteral Nutrition Prior Authorization Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. Medi-Cal Rx encourages submission through CoverMyMeds, which can often return real-time determinations, and requests can also go through the Medi-Cal Rx portal. Fax and mail to the Medi-Cal Rx Customer Service Center remain available for paper requests.
For tube-fed patients, more than 800 kcal/day of an infant product or 2,000 kcal/day of other products. For oral feeding, more than 800 kcal/day for infant products, 1,200 for patients 22 and older, or 1,000 for patients 21 and younger.
One form per member. If PA requests are needed for multiple members, a separate form must be submitted for each, and every applicable section on every page must be completed fully and legibly.