Members of Molina Healthcare have no co-pays or out-of-pocket costs for covered prescription medications.
To manage the pharmacy benefit for our Members, Molina 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.
Beginning Jan. 1, 2020, the Ohio Department of Medicaid (ODM) requires all Medicaid managed care plans and Medicaid Fee-for-Service (FFS) to use the same Unified Preferred Drug List. This initiative helps Ohio Medicaid meet the following goals:
- Create a standard process across Ohio Medicaid FFS and the managed care plans to support population health initiatives
- Reduce administrative burden for providers by simplifying and streamlining the prescribing and prior authorization processes
- Coordinate clinical care for Ohio’s Medicaid population
Preferred Drug List
Effective beginning Jan. 1, 2020: Unified Preferred Drug List
Some drugs require prior authorization (PA). We may require providers to submit information to us to explain why a specific medication and/or a certain amount of a medication is needed. We must approve the request before members can get the medication. We may require prior authorization for a drug if:
- There is a pharmacy alternative drug available
- The drug can be misused/abused
- There are other drugs that must be tried first
Also, some drugs may also have quantity (amount) limits and some drugs are never covered, such as drugs for weight loss.
Prior Authorization Form
Maximum Allowable Cost Appeal Process
MAC Appeal Process
Generic Prescription Drug Policy
If a brand name drug is ordered for a Molina Healthcare Medicaid Member and there is a preferred generic drug available, Molina Healthcare will cover the generic drug. If the member must have the brand name drug instead of the generic drug, the prescribing provider must submit a prior authorization request form to Molina Healthcare’s Pharmacy Department explaining why the preferred medicine will not work for the member. We review prior authorizations on an individual basis.
In some cases, Molina Healthcare requires members to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the member’s medical condition, Molina Healthcare may not cover Drug B unless you try Drug A first. If Drug A does not work for the member, Molina Healthcare will then cover Drug B.
Coordinated Services Program (CSP)
The State of Ohio permits MCPs to develop and implement programs to assist certain members that have received drugs that are not medically necessary to establish and maintain a relationship with one provider and/or pharmacy to coordinate treatment. Members selected for Molina Healthcare’s program will be provided additional information and notified of their state hearing rights, as applicable.
Molina Healthcare’s Multi-Pronged Approach to Fighting Opioid Drug Abuse
To prevent a member’s condition from worsening in an urgent situation after hours, it may be necessary to dispense a 72-hour supply of an acute medication before prior authorization may be obtained from Molina Healthcare, in cases where the medication is non-PDL or requires PA. (Example: A member is discharged from a hospital after regular business hours with an antibiotic or seizure medication.) Pharmacists are to use their professional judgment. Molina Healthcare will reimburse the pharmacy for the 72-hour supply at contracted rates for those prescriptions. Pharmacies are instructed to call 1-800-642-4168 on the following business day to obtain an authorization to allow the urgent after-hours prescription to process online. It is advised and expected that the pharmacy will provide reasonable documentation of cases where medications were dispensed under these circumstances.
Specialty Pharmacy Standards
Pharmacies that meet the pharmacy network standards and accept specialty rates can submit an application to CVS Caremark to enroll in the Specialty Pharmacy network. In order to enroll as a specialty pharmacy within Molina Healthcare of Ohio’s network, the specialty pharmacy must meet the
credentialing standards of any participating network pharmacy, as well as meet the following standards specific to specialty pharmacies.
JCAHO or ACHC: Accreditation with the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) for Homecare at all Specialty pharmacy mail service pharmacy locations or the Accreditation Commission of Health Care, Inc. (ACHC) in Specialty Pharmacy.
URAC: Provider must have current accreditation with the Utilization Review Accreditation Commission (URAC) for Specialty Pharmacy.
Verified Internet Pharmacy Practice Sites (VIPPS): Provider must have certification if conducting pharmacy practice on the Internet.
Adherence Management: Documentation of a proactive adherence management, tracking and reporting process.
Audit Findings: No audit findings of willful or material non-compliance over the past five (5)
Automated Dispensing Equipment: Documentation of the maintenance and monitoring of the performance of independent external vendor, with new studies done whenever new materials are introduced into the process.
Performance Standards and Guarantees:Compliance with performance standards and guarantees related to dispensing accuracy, delivery, customer service, patient satisfaction, compliance/adherence, therapy-specific clinical services. Provider shall demonstrate use of Lean Sigma tools and practices.
Quality Management Program: Documentation of a Quality Management Program to identify, address and resolve quality problems related to dispensing and distribution, medication safety, drug inventory management, customer service, and clinical pharmacy services.
Recalls: Maintain written policies and procedure to document lot numbers and inform patients and prescribers of drug product recalls and other safety information related to products dispensed.
Reports: Plan Sponsor reporting on a quarterly basis or other specified reporting period, including compliance, specialty prescription delivery, customer service phone, prescription dispensing accuracy, biotech, patient satisfaction survey, utilization reporting, dedicated resources and staffing, complaints and issues, Therapy-Specific Clinical Programs (Hemophilia, PAH, RSV, Growth Hormone and Hepatitis C).
Training: Written orientation, therapy and disease training and continuing education plans for employees who provide specialty pharmacy services.
Utilization Management: Comprehensive screenings for drug-drug interactions and provide prior authorization and utilization management services.
Waste Management: Services that help patient manage the quantity and quality of medication on hand.
These specific standards are set to provide patients with access to the highest quality specialty pharmacies’ services and promote patient satisfaction and clinical outcomes. To initiate the enrollment process, specialty pharmacies should send a request to firstname.lastname@example.org.
If you have questions, call the Provider Services Department at (855) 322-4079.
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