Benefits and Services

Welcome Molina Healthcare of Virginia members!

With your Molina Medicaid benefits, you’ll get standard benefits like:

Primary care provider (PCP) and specialist visits

PCP visits – Your PCP will provide most of your basic health care. You will usually see your PCP for most of your routine health care needs like exams, regular check-ups, vaccinations and other treatments to keep you well. You should call your PCP whenever you have a medical question or concern. Your PCP can also refer you to the hospital or specialists when needed.

If you have a disabling condition or chronic illness, you can ask that your specialist be your PCP. Women may also choose an OB/GYN for women’s health issues. This includes check-ups, follow-up care if there is a problem, and regular care during a pregnancy. Women do not need a PCP referral to see an OB/GYN provider in our network.

Your PCP must be part of the Molina provider network. If your PCP is not in our network, you will need to choose a new doctor. Read more information on how to choose a doctor.

Specialist visits – A specialist is a doctor who provides healthcare for a specific disease or part of the body. There are many kinds of specialists. If you need care that your PCP cannot give, your PCP may send you to a specialist. They will give you what is called a referral. This will let you see the specialist if they are in the Molina provider network. If we do not have a specialist in the Molina network to provide the care you need, we will get you the care you need from a specialist outside of the Molina network. You must get approval from Molina before seeing an out-of-network specialist.

If you have a disabling condition or chronic illness, you can ask that your specialist be your PCP.

Check your Molina member handbook for more information on PCP and specialist visits

Annual wellness exams

As a Molina member, you can get a physical exam from your PCP every year. This is also called an annual wellness exam. There is no cost to get this exam. Just call your PCP to set up an appointment to schedule an exam for you or your child.

Emergency services
An emergency is a sudden or unexpected illness, severe pain, accident or injury that could cause serious injury or death if it is not treated immediately. You are always covered for emergencies.

If you have an emergency, call 911 right away. You do not need to call Molina first. You do not need an authorization or a referral for emergency services. Calling 911 will help you get to a hospital. You can use any hospital for emergency care, even if you are in another city or state.

Tell the hospital that you are a Molina Healthcare of Virginia member. Ask them to call us at the number on the back of your member ID card.

What is a medical emergency?

This is when a person thinks he or she must act quickly to prevent serious health problems. It includes symptoms such as severe pain or serious injury. The condition is so serious that, if it doesn’t get immediate medical attention, you believe that it could cause:
- Serious risk to your health
- Serious harm to bodily functions
- Serious dysfunction of any bodily organ or part
A medical emergency can also happen if a pregnant woman is in active labor and:
- There is not enough time to safely transfer her to another hospital before delivery
- The transfer may pose a threat to her health or safety or to that of the unborn child
What is a behavioral health emergency?

A behavioral health emergency is when a person thinks about or fears they might hurt themselves or hurt someone else in the near future. You or a family member can call our Behavioral Health Crisis Line any time you need help. You or a family member can also call this number if you or they think you’re experiencing a drug overdose.

Behavioral Health Crisis Line
- (800) 424-4518 (TTY 711)
If you have an emergency when you are away from home

You may have a medical or a behavioral health emergency away from home. You may be visiting someone outside Virginia. While traveling, your symptoms may suddenly get worse. If this happens, go to the closest hospital emergency room. You can use any hospital for emergency care. Show them your Molina member ID card or tell them you are a Molina Healthcare of Virginia member.

You can get emergency care whenever you need it, anywhere in the United States or its territories. You do not need prior authorization for emergency services. If you need an ambulance to get to the emergency room, our plan covers that. Tell your PCP and Molina about the emergency as soon as you can (with 48 hours if possible). If you need follow-up care after your emergency to get better, Molina will cover that.

Visit our “How do I?” page to read about where you should go for healthcare if you aren’t sure you have an emergency.

Read more about emergency care in your Molina member handbook.
Addiction and Recovery Treatment Services (ARTS)
Most people with a substance use disorder can benefit from treatment, no matter how challenging the problem may seem.

Molina provides benefits for the following services to help:
- Inpatient and outpatient treatment
- Community-based treatment
- Medication-assisted treatment (MAT)
- Peer support services
- Case management
- Referrals to opioid treatment providers (OTP)
Talk to your PCP or contact Molina and request to speak to one of our ARTS Care Managers, to determine the best treatment option for you. Search for an ARTS provider in our online provider directory. You can also contact Member Services for help finding a provider who provides these services or a referral to one of our ARTS Care Managers.

More detail on ARTS benefits can be found in your member handbook.
Behavioral health services
If you live with a behavioral health challenge, we offer the following support to help you meet your recovery goals:
- Inpatient and outpatient treatment options
- Mental Health Services (MHS), including:
  - Mental health case management
  - Therapeutic day treatment
  - Day treatment/partial hospitalization for adults
  - Intensive community treatment
  - Mental health skill-building services
  - Intensive In-Home
  - Psychosocial rehabilitation services
  - Behavioral therapy
  - Crisis Intervention and Stabilization
  - Peer support services
  - Residential treatment services
Some behavioral health services are covered through Magellan of Virginia, the Department of Medical Assistance Services (DMAS) Behavioral Health Services Administrator. If you need behavioral health services, call us and we’ll help you find a provider that can help.

You can find more information on behavioral health services in your member handbook.

Behavioral health updates starting December 1st

On December 1, 2021, Virginia Medicaid will be adding new behavioral health services to Medicaid members.

New clinically-proven behavioral health services starting December 1, 2021

1. Multisystemic Therapy (MST)—treatment program for members ages 12-17 with disruptive behavior, mood disorder and/or substance use. MST is delivered in home and community settings and includes family and caregivers.
Members must have a referral for treatment of behavioral or emotional problems from the juvenile justice, behavioral health, school or child welfare systems.

2. Functional Family Therapy (FFT)—short-term treatment program for members ages 11-18 with serious emotional disturbance and substance use disorders. FFT is delivered in the member’s home. FFT also addresses parenting or caregiving challenges that affect the family unit.
Members must have a referral for treatment of behavioral or emotional problems by the juvenile justice, behavioral health, school or child welfare systems.

For most members any transitions to new services should be seamless and you won’t have to do anything. Please call Member Services at (800) 424-4518 (TTY 711) if you have any questions about services available after December 1, 2021. We’re here Monday through Friday from 8 a.m. to 8 p.m. local time.
Recovery Support (Peer) Navigation program
Recovery Support (Peer) Navigation is for members who are coping with mental health challenges or substance use issues. When you join this program you get a certified Recovery Support Navigator (RSN) who has lived experience with mental health or addiction issues who will work as a partner in your recovery. RSNs do many things to help you, like:
- Teach you about recovery and support you with developing your own recovery and resiliency goals
- Help you live successfully in your community
- Help you identify and obtain information on community resources
- Work with you in your community, your home, or your provider setting
This flyer tells more about our Peer Recovery Navigation program and how you can join:

Peer Recovery Navigation program
Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)

Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) is a program that provides comprehensive and preventive healthcare services for children under 21. This program tries to diagnose and treat health problems as early as possible.

If you have a child under age 21, EPSDT provides appropriate preventive, dental, behavioral health, developmental and specialty services. It includes coverage for immunizations, well child visits, lead investigations, private duty nursing, personal care and other services and therapies that treat or make a condition better. It will also cover services that keep your child’s condition from getting worse. EPSDT can provide coverage for medically necessary services even if these are not normally covered by Medicaid.

Molina provides most EPSDT services (note: EPSDT services are not covered under FAMIS). However, there may be some EPSDT services, like pediatric dental care you’ll get through the Medicaid fee-for-service program. Read more about EPSDT in your member handbook. You can also call Member Services for help with these services.

Family planning services
Family planning services are included with your Molina standard benefits. These services include:
- Devices
- Drugs (including long acting reversible contraception)
- Supplies for the delay or prevention of pregnancy
You are free to choose your method for family planning through in-network or out-of-network providers. You do not need to get a service authorization or PCP referral for family planning services. Coverage does not include services to treat infertility or to promote fertility, nor does Family Planning Services cover payment for abortion services and no funds shall be used to perform, assist, encourage or make direct referrals for abortions.
Long-term Services and Supports (LTSS) for Cardinal Care members

Molina provides LTSS coverage for Cardinal Care Managed Care or Molina Medicare (HMO D-SNP) members. These services help older individuals and people living with disabilities meet their daily needs and maintain maximum independence. Your Care Manager will help you find and access services that let you live in your own home or other settings of your choice. They’re here to help you find options to improve your quality of life.

Molina covers nursing facility care for Cardinal Care members who meet the coverage criteria for that level of care. Some Cardinal Care members who qualify for nursing facility levels of care may qualify for a waiver that allows them to stay in the community and get help with their daily needs, called activities of daily living (ADL). They may have a person regularly come into their home to give them healthcare services. Molina Care Managers visit on-site at various nursing facilities. They can help you with getting nursing facility information, services, and facilitating approvals and authorizations.

Read more about Long-Term Services and Supports in your Cardinal Care Managed Care member handbook.

Other standard Medicaid and extra benefits

Other standard Medicaid benefits

Check your member handbook to see all the standard Medicaid benefits offered by Cardinal Care.

Dental

The Virginia Department of Medical Assistance Services (DMAS) now offers comprehensive dental services for all Medicaid members. This benefit is a response to the needs of our members and a recognition of the importance of oral health in achieving positive overall health outcomes.

Members inquiring about the SFC (Smiles for Children) program, click here.

Providers inquiring about the SFC (Smiles for Children) program, click here.

Extra Benefits

As an Molina member, you’ll get extra services that are generally not covered through Medicaid fee-for-service. These are known as “extra benefits”.

Cardinal Care extra benefits 2022

Benefits available on your smartphone

Special Cardinal Care programs for pregnant women and children
Pregnant women and new moms

Our Mother-Baby Connections program will guide you through early prenatal care and what to do if you think you may be pregnant. If you are pregnant, we will send text messages with health tips about each stage of pregnancy. These tips will tell you what to expect during your pregnancy, how to spot problems and how to prepare for delivery and parenthood.

Whether you are a first-time mom or already have kids, you might have questions or concerns in between doctor visits or after your baby is born. We’ll educate and support you during your pregnancy and the first year of your newborn’s life to help you and your child be as healthy as possible.

Our CenteringPregnancy program offers a supportive environment for pregnant women to share and learn together. Meet regularly with your care provider and up to 12 other pregnant members to discuss your feelings and experiences. Doctors and nurses can teach you about nutrition, how to deal with stress, caring for your infant and more.

You’ll also get extra benefits, like:
- Infant sleep sacks and diapers
- An invitation to baby showers hosted by Molina (hosted quarterly per region)
- “What to Expect When Expecting” book
- Rides to WIC appointments, Lamaze and parenting classes
Children

We’re here to help your kids grow into healthy young adults. To help them succeed, Molina members get these extra benefits:
- Annual sports physicals from a PCP for children ages 10-18
- One bicycle helmet per year for children under 18
- A backpack stocked with supplies and comfort items for children entering a new foster home
Please see your Cardinal Care member handbook for more information on these special programs.
HFI Supplemental Security Income

Are you having trouble working due to your health condition?

You may be able to get a monthly check from the Social Security Administration (SSA)! This check can help you with your living costs.

Finding out if you’re eligible takes time and the process to apply can be hard. That’s why we partner with Healthcare Financial Inc. (HFI) and their team of SSA experts to help you get the benefits you need. This service is offered to Molina Healthcare of Virginia members at no cost.

Find out if you’re eligible to begin the process—talk to an HFI member advocate today.

Call HFI at (833) 896-6610, Monday through Friday from 9 a.m. to 5 p.m.

The sooner you begin, the sooner you may be approved and can start getting monthly disability checks!

Apply for supplemental security income:
I’m a member
I’m a provider/case manager

If you have any question, please call Member Services at (800) 424-4518 (TTY 711). We’re available Monday through Friday from 8 a.m. to 8 p.m. local time.

Pharmacy Benefits

List of covered drugs

Molina has a list of covered drugs that we select with the help of doctors and pharmacists. This is called a preferred drug list. This list of covered drugs also includes all the drugs on the DMAS Preferred Drug List (PDL). The list tells you which drugs are covered by us and if there are any rules or restrictions on any drugs, such as a limit on the amount you can get.

To get medicines on the list of covered drugs, you need to get a prescription from your doctor first. Take the prescription to a pharmacy in the Molina network or have your doctor call it in.

Molina pays for enhanced over-the-counter (OTC) products for all members with an active prescription from a participating provider. These products can include, but are not limited to:

Glucosamine with or without chondroitin
Fish oil
Saliva substitute
Skin or wound products
Psyllium
Fleet prep kits
Various vitamins or combinations not covered by the Commonwealth’s Pharmacy Manual and Covered Services

Please review this list to find out if your drugs are covered. If you would like a paper copy of the list of covered drugs, please call Member Services and we will mail you a copy. The list may change during the year.

If you are on a drug that is impacted by a change to the list of covered drugs, you will be notified in writing 30 days prior to the change taking effect.

If you have any questions about your medicine(s) or about your Molina pharmacy benefits, please call our Member Services team.

List of covered drugs -- Effective July 2023

List of covered drugs -- Effective October 2023

List of covered drugs -- Effective January 2024

Searchable Formulary

Medical Preferred Drug List

icon_pdf Physician Administered Preferred Drug list -- updated February 2024

Reimbursement Claim Form

icon_pdf Prescription Reimbursement Claim Form -- updated December 2023

Direct Member Reimbursement (DMR)

If you have Medicaid coverage with Molina Healthcare of Virginia (and no other coverage like Medicare), DO NOT pay for any prescription drugs. Call the Member Services number (800) 424-4518 on your card if you are told to pay. If you go to an out-of-network pharmacy, you will have to pay the full cost of your prescriptions. Molina will only reimburse you for prescription medications dispensed to you while you have Medicaid coverage with Molina.

Member reimbursement happens when you ask us to pay you back for the prescription drug(s) you paid for with your own money. If you used your own money to pay for a prescription that is covered by your plan, you may request a reimbursement if any of the following happened:

You didn’t use your member ID card
You didn’t use your member ID card at an in-network pharmacy.
You used an out-of-network pharmacy because:
- You needed drugs while traveling away from home and couldn’t go to your regular pharmacy
- You were unable to get drugs in a timely manner from your regular pharmacy
- You were forced to leave your home due to an emergency
- The pharmacy billed the wrong plan (if you have other coverage)
- You receive the drugs from an out-of-network pharmacy associated with an emergency department, clinic, or outpatient facility

You paid out-of-pocket for a medication when a prior authorization was in place.
The pharmacy billed the wrong plan (if you have other coverage)

Please fill out the Prescription Reimbursement Claim Form neatly and completely and attach a copy of your cash register receipt. If your prescription is a compound, please include each ingredient, dispensing facility, each ingredient cost, and prescription name. The pharmacy should help you fill out this portion. Send the completed form to the CVS Caremark address provided on the form.

Getting your medicines

For new medicines – When you get a prescription from your doctor, ask them to send it to a network pharmacy near you. You can find a list of pharmacies that work with Molina in our online provider directory. You may also take the prescription to a pharmacy that works with Molina and drop it off yourself.

For medicines you already take – If you already have medicines at a pharmacy that’s not on our list, you will need to pick a new in-network pharmacy. Once you do, simply ask the new pharmacy to get your prescription from your old pharmacy. Make sure you bring your Member ID card so you can show it to the pharmacist.

Specialty pharmacy program

Molina wants to help you get the care you need. Maybe you need to take a specialty medicine. Specialty medicines can be oral, but many times they are injected, infused, or inhaled medicines. These may need special storage or handling. Molina limits the amount of specialty drug fills to up to a 34-day supply.

CVS Specialty Pharmacy is our preferred specialty pharmacy. We’d like you to get your specialty medicine sent through the mail from CVS Specialty Pharmacy. CVS Specialty Pharmacy will work closely with you and your provider to give you what you need to help manage your condition.

Services and programs to support your needs
CVS Specialty Pharmacy makes it easy for you to get your specialty medicine with helpful services like:

Coaching programs to help manage your condition
Free delivery to your home or another address within two days of ordering
Supplies such as syringes and needles at no cost
Highly trained pharmacists and nurses available to answer any questions
Insurance specialists to help you get the most out of your benefits
Online member portal where you can request refills and learn more

Get started today
If you have a new prescription or if you are requesting a refill from another pharmacy, please call CVS Specialty Pharmacy to get your medicine delivered to you at no cost. If you do not want to use CVS Specialty Pharmacy pharmacy, tell the pharmacy team member at the time of the call. They will make a change that will allow you to continue to get your specialty medicine at your current pharmacy.

Contact us
Have questions? Please call CVS Specialty Pharmacy at (800) 237-2767 (TTY/TDD 711). They're available Monday through Friday from 8 a.m. to 10 p.m. local time. The pharmacy is available 24 hours a day, seven days a week for emergencies.

Mail order pharmacy program

Molina uses CVS Caremark Mail Service Pharmacy to deliver 90-day supplies of medications you take regularly to your door. This benefit is permitted for medications included on the DMAS 90-day drug list. Please call CVS Caremark Mail Service Pharmacy at (844) 285-8668 (TTY/TDD 711) to start using this service. Additional information may be accessed at https://www.caremark.com.

Join CVS Caremark for quick and easy digital tools to help you manage your health.

Do you use a CVS Caremark pharmacy to fill your medications? Join CVS Caremark today to access digital tools to help you manage all your healthcare and prescription needs. You can choose free home delivery of a medication, check your refill status, research your medication coverage, and so much more.

Everything you need is available online.

Visit our website for more information and register.

Drug recalls

List of recalled drugs

Medicare and Medicaid services

If you have Medicare and Medicaid, some of your services will be covered by your Medicare plan and some will be covered by Molina. We are your Cardinal Care Medicaid plan.

Types of services under Medicare

Inpatient hospital care (medical and psychiatric)
Outpatient care (medical and psychiatric)
Physician and specialist services
X-ray, lab work and diagnostic tests
Skilled nursing facility care
Home health care
Hospice care
Prescription drugs
Durable medical equipment

Types of services under Cardinal Care Medicaid

Medicare copayments
Hospital and skilled nursing when Medicare benefits are exhausted
Long-term nursing facility care (custodial)
Home and community-based waiver services, like personal care and respite care, environmental/home modifications and assistive technology services
Community behavioral health services
Medicare non-covered services, like some over the counter medicines, medical equipment and supplies, and incontinence products

For more information about these services, contact your Medicare plan, visit Medicare.gov, or call Medicare at (800) 633-4227 (TTY (877) 486-2048).

For detailed information about your benefits, please review your member handbook.

Safelink wireless phone

Some Molina members are also eligible to receive SafeLink Wireless smartphones.

There are three easy ways to enroll in the SafeLink Wireless program:

Visit www.safelink.com to apply online.
Print and fill out the application below mail it in.
Safelink Wireless member application (English)
Call SafeLink at (877) 631-2550.

Transportation

Do you need a ride to your healthcare appointments? Call MTM at (833) 273-7416 to schedule a ride. Visit our “How do I?” page to read more about how to set up a ride to your appointments.

Read these FAQs to learn more about MTM transportation services:

Cardinal Care member FAQ

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