Prescription Drugs

presdrugs

What’s covered

Members of Molina Healthcare have no co-pays or out-of-pocket costs for covered prescription medications.

Molina Healthcare uses an Over-The-Counter (OTC) and Durable Medical Equipment (DME) Products List. These products are available at no cost through the Molina Healthcare Medicaid pharmacy benefit. A prescription is required for these products.

Preferred Drug List (PDL)

Molina Healthcare uses a Preferred Drug List (PDL). A PDL is a list of prescription drugs that are recommended for doctors to use. A PDL is also called a Formulary.

Molina Healthcare uses the same Unified Preferred Drug List as all Medicaid managed care plans and Medicaid Fee-for-Service (FFS) in Ohio.

Using one drug list across all managed care plans and Fee-for-Service helps prescribers and members know which drugs are covered with or without prior approval.

Prescription drugs

Prescription medications are covered when:

  • They are ordered by your provider or another provider treating you or your child and the drug is listed on the Unified Preferred Drug List.
  • They are ordered or given while you are in an emergency room or hospital.
  • They are given while you are in a rest home, nursing home or convalescent hospital and they are ordered by a plan provider for a covered service and you got them through a pharmacy that is in the Molina Pharmacy Network.
  • They are prescribed by a primary care provider (PCP) or other provider whose services do not require an approval.

Generic medications

Generic drugs have the same ingredients as brand name drugs. To be FDA (government) approved, the generic drug must have the same active ingredient, strength and dosage (formulation) as the brand name drug.

If your provider orders a brand name drug and there is a preferred generic available, Molina Healthcare will cover the generic medication. If your provider says that you must have the brand name drug instead of the generic, they must submit a prior authorization request to Gainwell, the Single Pharmacy Benefit Manager (SPBM), explaining why the preferred medicine will not work for you. The SPBM reviews prior authorizations on an individual basis and considers your needs.

Single Pharmacy Benefit Manager (SPBM)

Molina Healthcare works with a Single Pharmacy Benefit Manager (SPBM) to help you with your prescription drug needs. The SPBM works with all Medicaid managed care plans to give you quality care and access to more pharmacies.

Gainwell is the SPBM that will help you with your prescription drug needs. Call Gainwell Member Services at (833) 491-0344 24 hours a day, 7 days a week if:

  • You need to ask about a drug.
  • You have trouble getting a prescription filled at the pharmacy. (Please do not pay for the prescription.)
    • Prescriptions are covered through Molina Healthcare's contracted pharmacies within Ohio.
  • You need an interpreter to communicate with the pharmacy about getting your medication.
  • You have an emergency and need drugs. Molina Healthcare will provide you with up to a 72-hour supply of the drug.

 

Learn more about the SPBM and how it benefits you at spbm.medicaid.ohio.gov.

Member Handbook

Your Molina Member Handbook tells you what you need to know about your Molina Healthcare of Ohio Medicaid Health Plan. Read more.

Resources

Find a pharmacy using the Pharmacy Provider Directory.

View the current Unified Preferred Drug List (UPDL).
View the Durable Medical Equipment Benefit.
View the Unified Preferred Drug List (PDL) Updates for the Current Quarter (30-Day Change Notice)
View the Over-The-Counter (OTC) and Durable Medical Equipment (DME) Products List (effective July 1, 2022).