The pharmacy benefit is changing for everyone who gets health care through an Ohio Medicaid managed care plan (MCP). Effective October 1, 2011, MCPs will cover all medically-necessary, Medicaid-covered prescription drugs and medical supplies.
For Molina Healthcare of Ohio members, this means Molina Healthcare will cover your prescription drugs and medical supplies, and you will need to get your prescription drugs and medical supplies at pharmacies and suppliers that accept Molina Healthcare.
While Molina Healthcare offers all medically necessary Medicaid-covered prescription drugs, we use a preferred drug list (PDL). These are drugs that we prefer our providers prescribe. CFC/ABD Preferred Drug Listing
Flu Shot (Vaccine)
Molina Healthcare members can receive a flu shot (vaccine) by visiting their health care provider. As an additional pharmacy benefit, effective October 20, 2011, members ages 19 and above can get their flu shot (vaccine) at CVS Pharmacies.
Some drugs may require Prior Authorization (PA). Your provider will submit information to us on why any specific medication or certain amount of medication is needed. We must approve the request before you can get the medication. You have the right to appeal if the request is not approved.
Reasons why we may require prior authorization of a drug include:
Prior Authorization List
- There is a generic or pharmacy alternative drug available
- The drug can be misused/abused
- There are other drugs that must be tried first
Also, some drugs may also have quantity (amount) limits and some drugs are never covered, such as drugs for weight loss.
The pharmacy will refill a prescription that usually requires Molina Healthcare prior authorization if Ohio Medicaid paid to fill the prescription on or after April 1, 2011, until the following dates:
- October 31, 2011, if the prescription is a controlled substance.
- January 31, 2012, if the prescription is a standard tablet/capsule antidepressant, standard tablet/capsule antipsychotic or injectible antipsychotic medication prescribed by a provider other than a psychiatrist.
- December 31, 2011, for all other prescriptions that require prior authorization by Molina Healthcare.
After the above dates, your provider will need to request prior authorization with Molina Healthcare for your prescription.
In some cases, Molina Healthcare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Molina Healthcare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Molina Healthcare will then cover Drug B.
Molina Healthcare requires the use of generic drugs if they are available. If your provider believes that it is medically necessary for you to have a brand name drug, the provider may submit a prior authorization request to Molina Healthcare. Molina Healthcare will review the request and determine whether to approve the brand name medication.
The State of Ohio permits Managed Care Plans (MCPs) to develop and implement programs to assist certain members that have received drugs that are not medically necessary to establish and maintain a relationship with one provider and/or pharmacy to coordinate treatment. Members selected for Molina Healthcare’s program will be provided additional information and notified of their state hearing rights, as applicable.
Call member services to find out whether your prescription drug(s) will require prior authorization now and in the future and to learn what you and your physician will need to do to get prior authorization for your drug(s).
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