Prescription medications are covered when:
- They are ordered by your provider or another doctor treating you or your dependents and the drug is listed on the Molina Healthcare Formulary.
- The Drug Formulary is Molina Healthcare’s list of approved drugs that doctors can order for you
- You get them through a pharmacy that is in the Molina Healthcare Pharmacy Network
- They are prescribed by a family planning doctor or other provider whose services do not require an approval
Formulary Preventive Drugs
Formulary Preventive drugs are drugs listed in the Molina Healthcare Drug Formulary which are considered to be used for preventive purposes, including all methods of birth control approved by the FDA, or if it is being prescribed primarily (1) to prevent the symptomatic onset of a condition in a person who has developed risk factors for a disease that has not yet become clinically apparent or (2) to prevent recurrence of a disease or condition from which the patient has recovered. A drug is not considered preventive if it is being prescribed to treat an existing, symptomatic illness, injury, or condition. Formulary Preventive drugs are offered at No Charge.
Formulary Generic Medications
Formulary Generic drugs are those listed in the Molina Healthcare Drug Formulary that 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 doctor orders a brand name drug and there is a Formulary Generic drug available, we will cover the generic medication.
Formulary Preferred Brand Name Drugs
Formulary Preferred Brand Name drugs are those drugs listed which, due to clinical effectiveness and cost differences, are designated as “Preferred” in the Molina Healthcare Drug Formulary. Formulary Preferred Brand Name drugs are prescription drugs or medicines that have been registered under a brand or trade name by their manufacturer and are advertised and sold under that name, and indicated as a brand in the Medi-Span or similar third party national database used by Molina Healthcare and our pharmacy benefit manager.
Formulary Non-Preferred Brand Name Drugs
Formulary Non-Preferred Brand Name drugs are those drugs listed in the Molina Healthcare Drug Formulary which are designated as “Non-Preferred” due to lesser clinical effectiveness and cost differences. Formulary Non-Preferred Brand Name drugs are prescription drugs or medicines that have been registered under a brand or trade name by their manufacturer and are advertised and sold under that name, and indicated as a brand in the Medi-Span or similar third party national database used by Molina Healthcare and our pharmacy benefit manager.
Getting an exception to the formulary
Drugs not listed on the formulary are called non-formulary drugs. For non-formulary drugs, you have the following options:
- You can ask your physician to order a similar drug that is listed in the formulary.
- You can ask your physician to request an exception so your non-formulary drug can be covered by your benefit.
- You can start the request for exception for a non-formulary drug.
- If you want to start the exception process, you can call Member Services or complete the form below.
Member Exception Form
Specialty Oral and Injectable Drugs
Specialty drugs are prescription legend drugs within the Molina Healthcare Drug Formulary which:
- Are only approved to treat limited patient populations, indications or conditions; or
- Are normally injected, infused or require close monitoring by a physician or clinically trained individual; or
- Have limited availability, special dispensing, handling and delivery requirements, and/or require additional patient support, any or all of which make the drug difficult to obtain through traditional pharmacies.
Molina Healthcare may require that Specialty drugs be obtained from a participating specialty pharmacy or facility for coverage. Molina Healthcare’s specialty pharmacy will coordinate with you or your physician to provide delivery to either your home or your provider’s office.
Mail order availability of Formulary Prescription Drugs
Molina offers You a mail order drug benefit on most of our formulary long term use drugs. Formulary Prescriptions drugs can be mailed to You within 10 days from order request and approval. Cost Sharing is a 90- day supply applied at two times Your appropriate Copayment or Percentage Cost Sharing based on Your drug tier for one month.
You may request mail order service in the following ways:
- You can also complete a Mail Service Order Form
- You can call the FastStart® toll-free number at 1 (800) 875-0867. Provide Your Molina Marketplace Member number (found on Your ID card), Your prescription name(s), Your doctor’s name and phone number, and Your mailing address.
- You can give Your doctor’s office the toll-free FastStart® physician number 1 (800) 378-5697, and ask Your doctor to call, fax, or electronically prescribe Your prescription. To speed up the process, Your doctor will need Your Molina Marketplace Member number (found on Your ID card), Your date of birth, and Your mailing address.
How do members get care?
Call Member Services 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 your service area. Prescriptions are covered outside of service area for emergency or urgent services only.
- You need an interpreter to communicate with the pharmacy about getting your medication.
- If you are deaf or hard of hearing, contact us through the National Relay Service by dialing 711.
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