DHCS 6560: Medi-Cal Rx Prior Authorization Request

California's Medi-Cal Rx program uses this four-page request when an outpatient drug or medical supply hits a claim edit that needs prior authorization. It applies to all Medi-Cal members, in fee-for-service and managed care alike, because Medi-Cal Rx rather than the health plan handles outpatient pharmacy authorization. Medi-Cal Rx reviews each request for medical necessity and notifies the submitter of its determination within 24 hours.

Who completes it

The prescriber completes all four pages: member, prescriber, medication and dispensing details, product use history, diagnoses with ICD-10-CM codes, required clinical information and the signed attestation. A pharmacy can also submit, using the Requestor Information block, but a member cannot initiate or submit a request.

How to fill it in

Member Information

Enter the member's name, date of birth, phone, Medi-Cal member ID, address, sex, height and weight, pregnancy status and allergies, then check where the member lives: home, skilled nursing facility, nursing facility (long-term care or intermediate care) or another location. An invalid client index number or BIC ID is one of the listed reasons a request cannot be accepted. Pages 2 to 4 repeat the member's first and last name at the top.

Prescriber Information

Give the prescriber's name, NPI, specialty, phone, fax and address. The fax number matters: Medi-Cal Rx sends deferral reasons and determinations to the requestor by fax, and mails a letter only when no fax number is available. Requests submitted electronically also show their status in the Medi-Cal Rx Provider Portal.

Requestor Information (if different than Prescriber)

Completed only when someone other than the prescriber submits the request, such as a pharmacy: business name or first and last name, requestor NPI, phone, fax and address. Members cannot initiate or submit a PA request, so this block is for providers. Medi-Cal Rx sends its response to the requestor.

Medication and Dispensing Information

Name the drug, strength, formulation, directions for use, length of therapy or number of refills, and quantity. Answer whether it is a DAW 1 request, whether it covers emergency services and whether it will be given in the provider's office, clinic or hospital. Mark a new request, a renewal or an appeal of a PA denied in the past 180 days. Renewals add the date therapy started, duration, how the patient received the drug and any known PA number.

1. Product Use History

State whether the patient has tried other medications for the condition and, if so, list up to three with drug name and dosage, specific dates of therapy and the response, reason for failure or allergy. Medi-Cal Rx requires less costly drugs and products, including those on its contract drug lists, to be tried or considered before it approves the requested one, so documented trials carry weight in the review.

2. Diagnosis and ICD-10-CM

List each diagnosis being treated in the two-column table with its ICD-10-CM diagnosis code. Medi-Cal Rx names diagnoses with their corresponding ICD-10-CM codes among the core details needed to establish medical necessity, and lists them first among the items that help a request avoid a deferral for missing information.

3. Required Clinical Information

Add symptoms, dated lab results, the justification for initial or continued therapy or a higher dose, and any contraindications to preferred drugs. Dated labs are required when needed to establish the diagnosis or evaluate response. Note exigent circumstances or anything else required under state and federal law. For off-label use or doses above FDA limits, attach peer-reviewed journal articles showing the use is safe and effective for the patient's age and diagnosis.

Attestation

The provider attests that the information is true and accurate and acknowledges that Medi-Cal Rx or its designees may audit and request the medical information behind it, then signs and dates. On faxed or mailed forms the signature must be original and written in ink; stamps, initials, typed or facsimile signatures are not accepted, and an invalid signature is a listed reason a request cannot be accepted.

Common mistakes

Putting more than one member on a request; Medi-Cal Rx requires a separate DHCS 6560 for each member.
Leaving applicable fields blank on any page; the form asks for every applicable section on every page, and missing information can get the request returned.
Signing a faxed or mailed form with a stamp, initials, a typed name or a facsimile signature instead of an original written signature.
Relying on continuation of therapy alone; Medi-Cal Rx states that it does not establish medical necessity without other clinical information.
Omitting tried alternatives, dated labs or ICD-10-CM codes, which leads to a deferral of up to 30 days and a denial if nothing more arrives.
Resubmitting a denied drug without marking it as an appeal; with no new information, Medi-Cal Rx treats the second request as a duplicate.

Submitting and payment

How to submit it: Submit through CoverMyMeds, the Medi-Cal Rx Provider Portal (registration required), an NCPDP P4 transaction from the pharmacy, fax or U.S. mail; requests are not taken by telephone. Faxed and mailed forms need an original handwritten signature, and the determination comes back by fax, or by letter when there is no fax number.
Who pays: An approval is sent to the Medi-Cal Rx point-of-sale system in real time so the pharmacy's claim for the drug can be reimbursed, and no authorization number is needed on the claim.

Good to know

One form per member. Medi-Cal Rx also takes Medi-Cal Forms 50-1 and 50-2 and California Form 61-211 by fax or mail, but prefers DHCS 6560; enteral nutrition has its own PA form.
If medical necessity cannot be established, the request is deferred for up to 30 days while Medi-Cal Rx waits for more information; with nothing new, a denial notice goes to the submitter and member.
Denied requests can be appealed within 180 days of the initial denial through the portal, fax or mail, clearly marked as an appeal. Medi-Cal Rx reviews appeals within 60 days.
Pharmacies may dispense a 14-day emergency supply without prior authorization when a delay would withhold a medically necessary drug, limited to two fills in 30 days for the same product and dose.

Get the official form

Download the current version from the source each time; forms change without notice.

Medi-Cal Rx Prior Authorization Request

Official page PDF

How this list is checked

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.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

How long does Medi-Cal Rx take to decide a PA request?

Medi-Cal Rx reviews requests for medical necessity and notifies the submitter of the determination within 24 hours. Outcomes are approval, approval with modifications, deferral for more information, informational (for example, no PA needed or a duplicate) or denial. CoverMyMeds requests can be approved in real time, and status in the provider portal may take up to 24 hours to appear.

Can a pharmacy submit the DHCS 6560?

Yes. The form has a Requestor Information block for a submitter other than the prescriber, and pharmacies can also send an NCPDP P4 request-only transaction. A pharmacy may start a CoverMyMeds request for the prescriber's office to complete, but only a prescriber can submit a completed request directly through CoverMyMeds.

Do Medi-Cal managed care plans use their own drug PA forms?

Not for outpatient pharmacy benefits. Medi-Cal Rx handles prior authorization of outpatient drugs for all Medi-Cal members, including people enrolled in managed care plans, so the DHCS 6560 goes to Medi-Cal Rx rather than to the plan. The form replaced the pharmacy treatment authorization requests used before Medi-Cal Rx launched.

What belongs in the Required Clinical Information section?

Symptoms, lab results with dates, justification for initial or ongoing therapy or a higher dose, and any contraindications to the preferred drugs. Off-label use or doses above FDA-approved limits need articles from major peer-reviewed journals. Medi-Cal Rx also states that continuation of therapy alone does not establish medical necessity, so chart notes and labs should show why the drug is needed.