Q. What is a drug formulary (list)?
A. Do you ever worry about how much your prescription drug will cost? Did you know Molina Healthcare has a list of drugs that it pays for? This is called a drug formulary. If you use a drug on the list, Molina Healthcare will pay for it. This means if you are on Medicaid you can get your medicine for free! Basic Health members have a co-pay depending if the medicine is brand name or generic.
Q. What drugs are on the formulary?
A. There are many drugs on the formulary list. There is at least one drug for each therapeutic category. A therapeutic category is a group of drugs used for a type of health problem like asthma, diabetes or ear infections. For each category, we will cover at least one drug and sometimes many more. This means there are drugs on the list that will help treat your medical needs. The list also has both brand name and generic drugs. Generic drugs work the same way as the brand name drug. We may cover both types or just one. But either way, we will pay for medicine that treats your condition! To get a copy of all the drugs we cover, go to Explore Your Health Plan and select your plan. You will find your Drug List in What’s Covered. You can also call Member Services at (800) 869-7165.
Q. How does Molina Healthcare decide which drugs to put on the formulary list?
A. 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 providers and pharmacists. They are from Molina Healthcare and from the medical community. The P&T Committee meets every three months. It meets to decide which drugs should be on the list. The drugs chosen are the ones that will serve you best. The choices are based on patient needs first!
The P&T committee also meets to go over FDA (Food and Drug Administration) reports. These reports talk about new drugs the FDA says are okay for use. They also talk about how well current drugs work. These reports help the committee. It helps them know if they should add drugs to the list or take some off. The drugs chosen for the list are those that are safe and those that work best.
Q. What if my drug is not on the formulary list?
A. If you find out your drug is not on the list, call Member Services at (800) 869-7165. Ask them to make sure your drug is not on the formulary. If they say it is not on the list, don’t worry! First, ask your provider if you can switch to another drug that we do cover. You can give your provider a list of the drugs we pay for. He or she may find another drug on the list that treats your medical condition the same way. If there is no other drug on the list that will help, we may still cover a drug not on the list! In this case, your provider must fill out a Prior Authorization Form and send it to us. Your provider will tell us why this is the only drug that will work for you. We will review the form. If we approve it, we will pay for your drug.
Q. What type of service should you expect from a network pharmacy?
A. 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!
Q. What is Prior Authorization?
A. At Molina Healthcare, we care about our members. That is why we have a prior authorization process for certain drugs. It means Molina Healthcare may have to approve a drug before you can take it. We only do this with some drugs. We may ask for it if:
- The drug on our formulary, says “PA”
- The drug is not on our list
- The drug is being used for a health condition that the Food and Drug Administration (FDA) did not approve
- 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. You might also need prior authorization if your provider wants you to take a higher dose of the drug you are on.
If your provider wants you to take a drug that needs prior authorization, he or she will need to send a Prior Authorization Form to Molina Healthcare. The form will say why your provider wants you to take that drug. We will review the form. In most cases, we will tell your provider within 24 hours if it is okay to prescribe it for you.
If we say it is okay to take the drug, we will tell your provider. If we do not say it is okay, we will tell your provider and send a letter to you, and your provider. It will tell you both why we said “no” to the drug. You can also call your pharmacy to find out if your drug has been approved or not. We will give your provider’s office all the information about your prescription. We will also send you a letter that tells you how to appeal our decision. This means you can still ask us to pay for your drug, even if we say “no”.
Q. Why do we have a Prior Authorization process?
A. 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.
- We want to make sure you take the right amount of the drug.
- We make sure the drug you are given is the right drug to treat your condition.
- We also want make sure it was prescribed to you by the right person.
- We want to make sure that 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 to pay for your care. Sometimes your provider may prescribe you a very expensive drug. There may be a less expensive drug you can use that works the same exact way. Sometimes it may work better or be safer to use.
Q. What is a utilization control?
A. We want to keep you safe when you take your medicine. That is why we have utilization controls. These are rules in the pharmacy computers we have for taking certain drugs. The rules are about whether or not you can take a certain drug and how much of it you can take.
Types of utilization controls
Prior Authorization: There are some drugs your provider may want you to take that need prior authorization. This means we have to approve a drug before you can take it. We do this to keep you safe. We want to make sure the drug you take is the right drug to treat your condition. We also want to make sure the drug was prescribed to you by the right person. We want to make sure you take a drug that will help you.
Dose/Age Check: This check is to make sure you take the right amount of a drug for your age, weight and height. The Food and Drug Administration (FDA) has directions for how much of a drug a person of a certain age, weight and height can take. We have dose/age checks to make sure the drug you are prescribed follows these directions. We don’t want you to take too much or too little of a drug. We want to make sure you are given the right amount of a drug to take.
Drug Interaction Screens: Some people see more than one provider. This means you might take more than one drug. But sometimes, when two or more different drugs are taken at the same time, it can be very dangerous to your health. That is why the pharmacy computers do drug interaction screens. These screens check to make sure the drug you are prescribed will not interact with another drug you take. If the pharmacy notices a problem, they will tell you and your provider.
We want to keep you safe. That is why we have these rules. We will not let you take the drug if there is a danger. We also have drug utilization reviews to enforce these rules. Our pharmacy computers make a review each time you fill a prescription. In a review, we look at the drug you are prescribed. We also look at your records. We make sure there is no problem with the drugs you take. We do this for all our members. It is to make sure you get safe care and to help keep you healthy!