Affinity by Molina Healthcare Essential Plan Prescription Drug Formulary
For medications not listed on the Formulary, providers may follow the same course of action as with a Coverage Determination, also called a Prior Authorization. This can be initiated by having your Provider call (800) 894-5979 and request a Coverage Determination for the medication(s) whether or not it is listed on the Formulary. Should this coverage be denied, an appeal can be made within 60 days of the initial denial by calling (800) 223-7242 or by completing the Member Appeal Form and mailing it at the following address:
Affinity by Molina Healthcare
1776 Eastchester Road
Bronx, New York, 10461
- At your local pharmacy
You can use your prescription benefit ID card at most chain and independent pharmacies across the country. Find a participating pharmacy near you using the Pharmacy Locator.
- Through the Caremark Mail Order Pharmacy
If your doctor has prescribed a drug for you to take for a long time (also called a Maintenance Medication), you may be able to have up to a 90-day supply delivered directly to your home or location of choice from our mail order pharmacy by using the following form:
Pharmacy Mail Order Form
- At your local pharmacy
These are high-cost, injectable, oral, infused or inhaled medications that are typically self-administered.
Specialty Guideline Management (SGM)
SGM is our utilization management program; administered by CVS Caremark, that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Prescribers may call 866.814.5506 to enroll patients in the Specialty plan design.
Comprehensive Contraception Coverage Act (CCCA)
You are covered for all forms of contraceptive drugs, devices and products approved by the U.S. Food and Drug Administration (FDA). This includes all FDA-approved over-the-counter contraceptive products as prescribed or as otherwise authorized under state or federal law. You are also permitted to receive an entire 12-month supply of a contraceptive at once.
Where the FDA has approved one or more therapeutic and pharmaceutical equivalent versions of a contraceptive drug, device or product, Affinity Health Plan is not required to include all of the therapeutic and pharmaceutical equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing.
Your contraceptive coverage is provided without any cost-sharing, including any deductible, coinsurance or copayment. Prior authorization, step therapy protocols, or quantity limits on a 12-month supply are not permitted for your contraceptive coverage.