Pharmacy Benefits

Molina Healthcare, in partnership with the Washington Health Care Authority (HCA), uses a Preferred Drug List (PDL). 

To access the Washington Health Care Authority (HCA) Preferred Drug List (PDL), please visit the Apple Health Preferred Drug List (PDL) page.

To view HCA drug coverage and policies, please visit the HCA Apple Health (Medicaid) drug coverage criteria page.

Molina follows HCA drug coverage criteria whenever HCA has established criteria.  In situations where HCA has not developed drug-specific criteria, Molina's drug coverage criteria will be applied to determine medical necessity.  Links to both HCA and Molina drug criteria are available on this page, with Molina criteria listed near the bottom. 


Molina Healthcare covered all Apple Health (Medicaid) medications that are determined to be medically necessary. To view the full formulary:

Sickle Cell and Gene Therapies

Hematopoietic Agents - Sickle Cell Disease Cell and Gene Therapies These services are carved out to Fee-for-Service (FFS). This policy outlines the coverage requirements for accessing these services through FFS.  

Opioids

On November 1, 2019, The Health Care Authority (HCA) is updating their opioid policy to include an MME (Morphine Milligram Equivalent) of 120 per day.

To access the opioid policy, visit the HCA opioid page at https://www.hca.wa.gov/billers-providers-partners/programs-and-services/opioids

Below are the available FAQ documents/resources for opioids on the HCA opioid page:


Physician Administered Preferred Drug List
This list includes medications that are preferred under the medical benefit. 

 

Physician Administered Preferred Drug List


Prior Authorization (PA)

Some medications require prior authorization (PA), which means Molina Healthcare must approve the medication or the requested amount before a member can receive.

If a medication requires a PA, approval must be granted before the prescription can be filled.  Reasons a request may not be approved include, but are not limited to:

  • A generic or clinically appropriate alternative is available
  • The medication has the potential for misuse or abuse
  • Other medications must be tried first

Some medications may also have quantity limits, which restrict the amount that can be dispensed within a specific time period.  

The following types of medications are not covered:

 

  • Medications used for weight loss
  • Medications used for erectile dysfunction
  • Medications used for infertility
  • Medications used for cosmetic purposes

 

Submitting a Prior Authorization Request

The Molina Healthcare Pharmacy team encourages providers to review the Preferred Drug List (PDL) and consider covered alternatives, when available, before submitting a Prior Authorization (PA) request. 

The PDL identifies which medications are covered and whether any coverage limits apply.  Molina follows the Washington Health Care Authority (HCA) PDL and covers only products that participate in the Medicaid Drug Rebate Program (MDRP). 

PA Forms

Drug Criteria

 

Urgent Requests

At the top of the standard PA form, there is an optional section for the provider to indicate if the request is for a reauthorization or is considered urgent:

Urgent Requests

 

PLEASE NOTE: By selecting "Urgent" the provider attests that:

  • an expedited review is needed, and
  • they believe a delay in treatment based on the standard review time may seriously jeopardize the patient's life, overall health or ability to regain maximum function, or would subject the patient to severe and intolerable pain.

Medication Exception Requests

The Prior Authorization/Medication Exception Request form must be filled out and include information related to the patient's need for a formulary exception. Once a case is received by Molina Healthcare, it will be reviewed for medical necessity in order of urgency and time/date received.

"Medically necessary" is defined by the State of Washington in WAC 182-500-0070 as, "a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, 'course of treatment' may include mere observation or, where appropriate, no medical treatment at all."

Overview of Fields

  • Patient Information* First Name, Last Name, Date of Birth and Member Identification Number (ID).
  • Physician Information* First Name, Last Name, Prescriber Phone, Prescriber Fax and Physician National Provider Identifier (NPI)
  • Medication Information* Drug Name, Strength and Directions
  • Diagnosis/Medical Justification* Must include at least a diagnosis and/or ICD-10 code. Medical justification can be added in this field to help Molina understand the provider's clinical rationale and the medical necessity for non-preferred medication. The comments section can be utilized for additional notes.
  • Previous Medications Tried/Failed Provider can indicate if alternative medications and/or therapies have been tried.

*This field is REQUIRED in order for a request to be considered complete

PLEASE NOTE: If medical justification and/or clinical information is missing, the request may result in a denial.

If the form is incomplete and/or medical justification is not included in the request, Molina Healthcare will fax a request for clinical information to the provider. Providers can help eliminate additional fax requests and delays in authorization determination by attaching clinical notes to the Prior Authorization/Medication Exception Request form.


Submitting a PA Request

We understand your time is important. To help you cut down on paper and save administrative time, you can submit a PA request electronically using the ePA Portal, certain electronic medical record systems and/or a CoverMyMeds account. For more information, click below:

How to register on the eAP Portal

How to register CoverMyMeds Account


Additional Policies and PA Forms

Emergency Fill Policy 

Opioid Attestation Form

For pharmacies that wish to appeal pricing, please visit the CVS pharmacy portal. For assistance with submitting appeals through the Pharmacy Portal please see the Pharmacy Portal section of the CVS Caremark Provider Manual. Provider may also submit Non-MAC appeals by calling 1-844-278-5713 or by calling 1-847-559-3977 for MAC appeals.


icon Adobe Acrobat Reader is required to view the file(s) above. Download a free version.