Drug Formulary
To view the Molina Healthcare of Utah Medicaid/CHIP Drug List(s), click below:
UT Medicaid Preferred Drug List
SureScript Real-Time Prescription Benefits
The following documents provide information pertaining to the CVS SureScript Real-Time Benefits now available to providers.
Pharmacy FAQ
- Which Medications Are Covered
- Preferred drugs for coverage are found on the drug formulary list. This drug list is updated quarterly.
- The formulary drug list and applied limitations (quantity, age, MED, PA etc) are reviewed and approved by a national Pharmacy and Therapeutics (P&T) Committee.
- The P&T committee members (physicians and pharmacists) are not employed by Molina and they must disclose any financial relationship or conflicts of interest with any drug manufacturers.
- Utah Medicaid Administrative rules indicate Medicaid has a mandatory generic drug policy except for drugs designated as "brand required over generic". Generic drugs must be used whenever possible.
- Many drugs not listed on the drug formulary are eligible for coverage, however, a Medication Exception Prior Authorization Request must be submitted with all necessary clinical documentation.
- Which Medications or Diagnoses Are Not Covered
- Diagnoses that are excluded for coverage as determined by federal or Utah Medicaid administrative rules such as:
- Fertility or sexual dysfunction treatments
- Weight loss, weight gain, or anorexia
- Cosmetic treatments such as hair growth
- Drugs that are excluded for coverage as determined by federal or Utah Medicaid administrative rules such as:
- Drugs that are not eligible for Federal Medicaid funds or Medicaid Drug Rebate Program
- Drugs determined by the Federal Drug Administration (FDA) to be less than effective and identical than related or similar drug (frequently referred to as "DESI 5 and 6" drugs
- Nonprescription or Over-the-Counter (OTC) drugs that are not found on the drug formulary
- Vitamins or Fluoride supplements, except for prenatal vitamins for pregnant women or products for children through age 5
- Breast milk, breast milk substitutes, baby food, medical food products, or prescription metabolic products for in-born errors of metabolism (e.g. phenylketonuria and maple syrup urine disease) as defined in UT Medicaid Provider Manual
- Convenience Dosage Forms (e.g. transdermal patches) not listed on drug formulary
- Drugs for which the manufacturer requires, as a condition of sale, that associated tests and monitoring services are purchased exclusively from the manufacturer or its designee
- Bulk powders for compounded prescriptions
- Drugs for experimental or investigational uses
- Some drugs are managed by the State of Utah Medicaid agency and not Molina - these drugs are "carved out"
- Antipsychotics (including injectables)
- Anticonvulsants
- ADHD Stimulants
- Antidepressants
- Antianxiety Agents
- Transplant Immunosuppressants
- Hemophilia Drugs
- Mood Stabilizers
- Drugs to treat substance abuse disorders
- COVID-19 vaccines, antivirals, and monocloncal antibodies
- The Medicaid carve out drugs are not applicable to CHIP members
- Diagnoses that are excluded for coverage as determined by federal or Utah Medicaid administrative rules such as:
- Where Can Molina Members fill their Prescription Drugs (Pharmacy Network)
- Members must receive drugs from in-network pharmacies and facilities
- Molina's pharmacy network managed by Caremark and a list of in-network pharmacies can be found on the Molina website homepage by clicking the tab "Find a Doctor or Pharmacy
- Specialty medications must be filled by CVS specialty pharmacy or other in-network specialty pharmacy
- How Do I Know if a Drug Requires a Prior Authorization
- The drug formulary or preferred drug list shows a PA indicator next to drug name
- The prescription drug benefit has safety alerts that may trigger prior auth for further safety or medical necessity review such as therapeutic duplications, serious drug-drug interactions, exceeding MME or quantity limits, etc.
- The provider home page contains the CPT/HCPCS code lookup tool for physician administered drugs
- Providers may also look up PA status using the most recent Prior Authorization Code Matrix found under the tab “Forms” on the Molina Provider website
- Prior Auth requirements change quarterly - please reference the most current formulary drug list, PA matrix, or CPT/HCPCS code lookup tool
- How Do I Submit a Drug Prior Authorization Request
- All outpatient drug prior auth requests, whether covered through the medical or pharmacy benefit, must be sent via fax to 866-497-7448
- All outpatient drug prior auth requests require clinical documentation including chart notes and the appropriate Molina prior auth form
- For pharmacy benefit drug requests, please use the Medication Exception Request PA Form found under the "Forms" on the Molina Provider website
- For medical benefit/HCPCS drug requests, please use the J-code Drug PA Form found under the tab "Forms" on the Molina Provider website
- A few drugs, including Opioids and Synagis, require their own PA form found under the tab "Forms" on the Molina Provider website
- Please do not submit any drug PA requests using the Provider Portal; doing so may result in delays for your request
- When Will I Receive a Decision for a Drug Prior Authorization Request
- Standard authorization requests will be decisioned within one week after all required information is received
- Expedited or urgent requests will be decisioned within 72 hours after all required information is received
- Your office will be faxed a copy of the approval or denial letter that is addressed to the member
- If more information is requested from our medical reviewers, your office will be faxed a letter titled "Notice of Insufficient Information". This letter will give the details for what additional information needs to be submitted by the provider office
- The definition of an expedited or urgent request should be used when the requested treatment is required to prevent serious deterioration of the member's health or could jeopardize the member's ability to regain maximum function
- Requests outside of this definition should be submitted as standard or non-urgent
- How Can I Ask for a Reconsideration or an Appeal of a Treatment Denial
- A copy of the member denial or "Notice of Action" letter will be faxed to your office. This letter states why the request for drug treatment was denied and contains the details needed to appeal a denial
- The member or a member's representative (the provider) may file the request to appeal
- The member or member's representative has up to 60 calendar days from the denial date to file a standard or expedited appeal request
- After the Notice of Action or denial letter is received, a request for an appeal may be submitted by writing, fax, or phone to the Molina Grievance and Appeals Department. The contact information for this department is given in the Notice of Action letter
**For other questions not answered in this Question and Answer section, please contact your Provider Services Representative or contact Molina Provider Services at MHUProviderServicesRequests@MolinaHealthcare.com**