Effective October 1, 2011, Molina Healthcare of Ohio will cover all medically necessary Medicaid-covered prescription drugs and medical supplies. This change affects everyone who gets health care through an Ohio Medicaid managed care plan. 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.
Preferred Drug List
The Molina Healthcare of Ohio Preferred Drug List (PDL) was created to help manage the quality of our members’ pharmacy benefit. These are the drugs that we prefer providers prescribe. The PDL is the cornerstone for a progressive program of managed care pharmacotherapy. Prescription drug therapy is an integral component of the member’s comprehensive treatment program. The PDL was created to ensure that Molina Healthcare members receive high quality, cost-effective drug therapy.
ABD/CFC Preferred Drug Listing
Prior Authorizations
Some drugs require prior authorization (PA). We may require providers to submit information to us to explain why a specific medication and/or a certain amount of a medication is needed. We must approve the request before members can get the medication. Reasons why we may prior authorize a drug include:
- 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.
Prior Authorization Form Prior Authorization List
Generic Prescription Drug Policy
Molina Healthcare requires the use of generic drugs if they are available. If the provider believes that it is medically necessary for the Molina Healthcare member 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.
Step Therapy
In some cases, Molina Healthcare requires members to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the member’s medical condition, Molina Healthcare may not cover Drug B unless you try Drug A first. If Drug A does not work for the member, Molina Healthcare will then cover Drug B.
Care Management
The State of Ohio permits 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.
“Emergency” Prescriptions
To prevent a member’s condition from worsening in an urgent situation after hours, it may be necessary to dispense a 72-hour supply of an acute medication before prior authorization may be obtained from Molina Healthcare, in cases where the medication is non-PDL or requires PA. (Example: A member is discharged from a hospital after regular business hours with an antibiotic or seizure medication.) Pharmacists are to use their professional judgment. Molina Healthcare will reimburse the pharmacy for the 72-hour supply at contracted rates for those prescriptions. Pharmacies are instructed to call 1-800-642-4168 on the following business day to obtain an authorization to allow the urgent after-hours prescription to process online. It is advised and expected that the pharmacy will provide reasonable documentation of cases where medications were dispensed under these circumstances.
Questions
If you have questions, call the Provider Services Department at 1-800-642-4168.
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