What is a drug formulary (list)?
Molina Healthcare uses a special list of drugs we cover called a drug formulary. If your doctor prescribes a drug on the list, Molina Healthcare will cover it when certain rules are met. You may have a drug copay depending on the drug, your plan, or income level. Some types of drugs do not have copays such as birth control, formulary blood sugar monitors and testing strips or vaccines.
What drugs are on the formulary (drug list)?
There are many different types of drugs on the formulary list. There is at least one drug (and usually more) for each category or group of drugs used to treat different health problems. These types of health problems include conditions like asthma, diabetes, or ear infections. This means there are many drugs options that will help treat your medical needs. The list includes both brand name and generic drugs. Generic drugs have the same ingredients and work the same way as the brand name drug. You will find your formulary (drug) list in the "What’s Covered" section under the section called "Prescription Drugs." You can also call Member Services at (888) 483-0760 to get a copy of your drug list.
How does Molina decide which drugs to put on the formulary (drug list)?
The drugs on this list are chosen by Molina Healthcare’s Pharmacy and Therapeutics (P&T) Committee. This committee is a team made up of doctors and pharmacists. They do not work for Molina Healthcare and are from the medical community outside of Molina. The P&T Committee meets every three months to decide which drugs should be on the list. The drugs chosen are the ones that will serve you best, patient needs come first! The drugs chosen for the list are those that are safe, and work best based on information used by the medical community for treatment.
What if my drug is not on the formulary (drug) list?
If you find out your drug is not on the list; you have the following options:
- Ask your provider if you can switch to another similar drug that we do cover.
- If there is no other drug on the list you can switch to, ask your doctor to submit a Prior Authorization request. This request asks Molina for an exception to cover your drug.
- You can complete a certain form to start the exception process.
- You can also start the request for an exception by calling Member Services at (888) 483-0760. First, ask them to make sure your drug is not on the formulary list.
What is Prior Authorization (PA)?
At Molina Healthcare, we care about our members and their quality of health care. That is why we have a prior authorization process to make an exception to cover certain drugs not on the drug list (formulary). It means Molina Healthcare may have to approve a drug before we cover it. Some, not all drugs, may require a special authorization if:
- The drug on our formulary, says “PA” (Prior Authorization).
- The drug is not on our formulary (drug) list.
- The drug is being used for a health condition that the Food and Drug Administration (FDA) has not approved its use for.
- Your doctor is requesting a drug at a higher than recommended dose or there are potentially serious interactions between your drugs.
- The prescription is being refilled too soon after it was first filled.
- For example, if your drug is lost, stolen, or spilled, you might need prior authorization to get a refill.
How will I know if a drug is approved to use or not?
- If your provider wants you to take a drug that needs prior authorization, he or she will need to send a Prior Authorization Form with office visit notes to Molina Healthcare. The form and notes will tell Molina why your provider wants you to take that drug.
- A pharmacist or medical doctor will review the requested drug. In most cases, we will tell your provider within 24 hours if your drug is okay to use (approved) or not okay to use (denied).
- If we say it is okay to take the drug, we will fax your provider the approval. This approval will tell your provider how long your drug has been approved for, usually three months up to one year depending on your medical reason for using the drug.
- If your drug is not okay to use (denied), we will fax your provider and send a letter to you. This denial letter will tell you both why we said “no” to your requested drug.
- We will also send you a letter that tells you how to “appeal” or reconsider our decision. This means you or your provider can still ask us to pay for your drug, even if we say "no."
- You can also call your pharmacy to find out if your drug has been approved or not.
What can I do if my drug is not approved to use (denied)?
- If you don’t understand your letter that tells you why the drug was denied, you can call your provider or call Member Services at (888) 483-0760.
- Sometimes your drug isn’t approved because your provider didn’t send us all the information we asked for. Often after your doctor sends us more information, the requested drug is approved.
- You can ask your provider if you can switch to another similar drug/dose that we do cover on the drug (formulary) list.
- You or your provider can submit an appeal to ask Molina to reconsider approving your drug.
- Your denial letter will give you all the details you need to start the appeals process.
- A medical doctor who works for Molina will review your appeal asking us to approve your drug.
- If the doctor makes the same decision that your drug is not okay for you to use (the denial is upheld), you still have other options to have your requested drug reviewed by someone else. These options are also discussed in your original denial letter.
- If a doctor or pharmacist decides to “overturn” our decision to say no and approve your drug, we will fax your provider. This approval will let your provider know your drug is okay to use and has been approved.
Why do we have a Prior Authorization process?
The reason we have this process is to keep you and your family safe and healthy. We ask for prior authorization because we want to make sure:
- A drug is safe for you to take.
- You take the right amount of the drug.
- The drug you are given is the right drug to treat your condition.
- The drug was prescribed to you by the right person.
- The drug will not mix in a dangerous way with any other drugs you take.
We also have this process because we are expected to make the best use of the money, we are given by the state agency to pay for your care. In health care covered by government plans, there can be fraud, abuse, or wasteful use of resources that do not meet standards of medical care. Sometimes your provider may prescribe you a very expensive drug, or a drug that requires you to be watched closely for serious side effects. There may be a less expensive drug you can use that works the same exact way to treat your same condition. Sometimes the cheaper drug may also work better or be safer to use.
What type of service should I expect from a network pharmacy?
There are certain services you should get from our network pharmacies. These services are there to help you. They help you know how to take your medicine the safe and healthy way. When you go to a network pharmacy:
- You should expect to be asked if you want to speak with a pharmacist. This is called a patient consult.
- During a consult you can ask the pharmacist many questions. You can ask how to take your medicine. You can also ask when you should take it. For example, you might need to take it with or without food. Ask about how to take your drug the safe way.
- During the consult, the pharmacist may tell you:
- What the drug is for and how it works.
- Side effects the drug may cause.
- How to store the drug. Some drugs must be kept at a certain temperature or in a certain light, so they won’t be ruined.
- About any other drugs you should not take. Sometimes when two drugs are taken together, it can be dangerous for you. Some drugs can stop your medicine from working.
- You can also ask for a medication profile review. This is when a pharmacist checks the computer for all of the drugs you are taking. He or she will tell you information about them. You will be told the best way to take each one throughout the day. The pharmacist will also make sure it is safe for you to take the drugs together during the day. If you take any vitamins or herbal remedies, tell your pharmacist. He or she will let you know if it is okay to take them with your other drugs.
- You should also be able to ask that information on your prescription (Rx) bottle be in a different language.
- During flu season, some of the network pharmacies may offer flu shots for you as a Molina Healthcare member. The flu shots are free of charge. Ask if your pharmacy offers flu shots for Molina Healthcare members. You should expect these services from your pharmacy. Be sure to take advantage of what your pharmacy offers. We only choose network pharmacies that serve you best. We work with our network pharmacies to keep you safe and healthy!
- There may be other vaccines that are covered. To see what vaccines are covered, check the formulary list.
Pharmacy Questions and Answers
- What is a drug formulary (list)?
- What drugs are on the formulary (drug list)?
- How does Molina decide which drugs to put on the formulary (drug list)?
- What if my drug is not on the formulary (drug) list?
- What is Prior Authorization (PA)?
- How will I know if a drug is approved to use or not?
- What can I do if my drug is not approved to use (denied)?
- Why do we have a Prior Authorization process?
- What type of service should I expect from a network pharmacy?
Find your formulary (drug) list in the "What’s Covered" section under the section called "Prescription Drugs." You can also call Member Services at (888) 483-0760 to get a copy of your drug list.
If you have any problem reading or understanding this or any Molina Healthcare information, call Member Services at (888) 483-0760. We can explain in English or in your primary language. You may request printed versions of these materials and they will be sent to you free of charge and within five business days. We may have it printed in other languages. You may ask for it in braille, large print, or audio. If you are hearing impaired, dial 711 for the Utah Relay Service.