Drug Formulary

Note: The Health Care Authority (HCA) implemented the Apple Health Preferred Drug List (PDL) on January 1, 2018. All managed care plans and the fee-for-service program serving Apple Health clients will use this PDL.

HCA will add more drug classes to the Apple Health PDL beginning July 1, 2018. Additional drug classes that have been reviewed by the DUR Board will be added at this time and will continue to be added until all drug classes have been added to the Apple Health PDL.

The purpose of the Common Formulary is to:

  • Promote continuity of care
  • Reduce interruptions in a beneficiary's drug therapy due to a change in health plan
  • Streamline drug coverage policies and reduce administrative burden for providers
  • Facilitate collaboration among health plans

To access the HCA policies, please visit the HCA Apple Health (Medicaid) drug coverage criteria page.

Molina uses HCA criteria in all circumstances where the HCA has developed drug coverage criteria. In circumstances where the HCA has not developed criteria, Molina will utilize our criteria to evaluate medical necessity.

We have enclosed a link to the HCA's drug policies at here. The Molina drug criteria is listed near the bottom of this page.

To access drug specific PA forms, please visit PA forms section below.


Prescription Drugs & Medication

Molina Healthcare covers all medically necessary Apple Health (Medicaid)-covered medications. We use a preferred drug list (PDL), which consists of the drugs that we prefer our providers to prescribe.


Opioids

On November 1, 2019, The Health Care Authority (HCA) is updating their opioid policy to include an MME (Morphine Milligram Equivalent) of 120 per day.

To access the opioid policy, visit the HCA opioid page at https://www.hca.wa.gov/billers-providers-partners/programs-and-services/opioids

Below are the available FAQ documents/resources for opioids on the HCA opioid page:


Over-the-Counter (OTC) Drugs

Molina Healthcare will only cover OTC products that are covered through the Apple Health (Medicaid) fee-for- service (FFS) program.

Over-the-counter drugs not listed on the PDL will not be covered.

 

Physician Administered Preferred Drug List

This list of medications is preferred under the medical benefit. 

Physician Administered Preferred Drug List


Prior Authorization (PA)

Some drugs require a PA, or Molina's approval, for a specific medication or a certain amount of a medication. If a drug requires a PA, we must approve the request before the member can get the medication. Reasons why we may not approve a request include, but are not limited to:

  • There is a generic version or a pharmaceutical alternative of the drug available
  • The drug can be misused/abused
  • There are other drugs that must be tried first

Some drugs may also have quantity (amount) limits. Drugs that we never cover include:

  • Drugs used for weight loss
  • Drugs used for erectile dysfunction
  • Drugs used for infertility
  • Drugs used for cosmetic purposes
  • Drugs whose labelers/manufacturers do not have a signed federal rebate agreement. View the covered customer rebate list.

For a complete list of non-covered/excluded drugs, please see the Excluded Medications section of our Formulary PDF.

Considerations for Submitting a PA Request

The Molina Healthcare Pharmacy team encourages providers, prior to submitting a Prior Authorization (PA) request, to review the PDL and consider covered alternatives, if applicable. The PDL identifies which medications are covered and whether there are coverage limits. Molina follows the Washington Health Care Authority's PDL and only covers products that participate in the Medicaid Drug Rebate Program (MDRP). If the product does not participate in the MDRP, it is excluded from coverage.

PA Forms

 

Drug Criteria

 

If the medication is listed on the PDL as a specialty (SP) medication and requires prior authorization, the following form, including clinical notes, is required:


Urgent Requests

At the top of the standard PA form, there is an optional section for the provider to indicate if the request is for a reauthorization or is considered urgent:

Urgent Requests

 

PLEASE NOTE: By selecting "Urgent" the provider attests that:

  • an expedited review is needed, and
  • they believe a delay in treatment based on the standard review time may seriously jeopardize the patient's life, overall health or ability to regain maximum function, or would subject the patient to severe and intolerable pain.

Medication Exception Requests

The Prior Authorization/Medication Exception Request form must be filled out and include information related to the patient's need for a formulary exception. Once a case is received by Molina Healthcare, it will be reviewed for medical necessity in order of urgency and time/date received.

"Medically necessary" is defined by the State of Washington in WAC 182-500-0070 as, "a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, 'course of treatment' may include mere observation or, where appropriate, no medical treatment at all."

Overview of Fields

  • Patient Information* First Name, Last Name, Date of Birth and Member Identification Number (ID).
  • Physician Information* First Name, Last Name, Prescriber Phone, Prescriber Fax and Physician National Provider Identifier (NPI)
  • Medication Information* Drug Name, Strength and Directions
  • Diagnosis/Medical Justification* Must include at least a diagnosis and/or ICD-10 code. Medical justification can be added in this field to help Molina understand the provider's clinical rationale and the medical necessity for non-preferred medication. The comments section can be utilized for additional notes.
  • Previous Medications Tried/Failed Provider can indicate if alternative medications and/or therapies have been tried.

*This field is REQUIRED in order for a request to be considered complete

PLEASE NOTE: If medical justification and/or clinical information is missing, the request may result in a denial.

If the form is incomplete and/or medical justification is not included in the request, Molina Healthcare will fax a request for clinical information to the provider. Providers can help eliminate additional fax requests and delays in authorization determination by attaching clinical notes to the Prior Authorization/Medication Exception Request form.


Submitting a PA Request

We understand your time is important. To help you cut down on paper and save administrative time, you can submit a PA request electronically using the ePA Portal, certain electronic medical record systems and/or a CoverMyMeds account. For more information, click below:

How to register on the eAP Portal

How to register CoverMyMeds Account


Additional Policies and PA Forms

Emergency Fill Policy 

Opioid Attestation Form

For pharmacies that wish to appeal pricing, please visit the CVS pharmacy portal. For assistance with submitting appeals through the Pharmacy Portal please see the Pharmacy Portal section of the CVS Caremark Provider Manual. Provider may also submit Non-MAC appeals by calling 1-844-278-5713 or by calling 1-847-559-3977 for MAC appeals.


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