Molinalogo

What’s covered

Molina Healthcare members have no co-pays or out-of-pocket costs for covered prescription medications.  

Single Pharmacy Benefit Manager (SPBM)

Molina Healthcare works with a Single Pharmacy Benefit Manager (SPBM) to help you with your prescription drug needs. The SPBM works with all Medicaid managed care plans to give you quality care and access to pharmacies. 

Gainwell is the SPBM that will help you with your prescription drug needs. Call Gainwell Member Services at (833) 491-0344, TTY 711, 24 hours a day, 7 days a week 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 Gainwell's contracted pharmacies in Ohio.
• You need an interpreter to communicate with the pharmacy about getting your medication.
• You have an emergency and need drugs. Gainwell will provide you with up to a 72-hour supply of the drug.

Learn more about the SPBM and how it benefits you at spbm.medicaid.ohio.gov.

Unified Preferred Drug List (UPDL)

Gainwell uses the Ohio Department of Medicaid's (ODM) Unified Preferred Drug List (UPDL). The UPDL is a list of prescription drugs that are recommended for doctors to use. The UPDL is also called a Formulary. 

The UPDL includes details on drugs, like quantity limits, age limits, and how these limits affect your coverage. The UPDL also has links to the information for each drug class. These documents include details on limits to your drug coverage. To view the UPDL and specific drug restrictions, click the link below.  

The same Unified Preferred Drug List is used for all Medicaid managed care plans and Medicaid Fee-for-Service (FFS) in Ohio.

Using one drug list across all managed care plans and Fee-for-Service helps providers and members know which drugs are covered with or without prior approval. 

If your provider orders a drug that is not covered under the UPDL, your doctor can submit a request for prior authorization to Gainwell for you. 

A prior authorization may be needed if: 

• Your doctor orders a non-preferred drug and there is a preferred drug covered under the same therapeutic class (Therapeutic Interchange).
• Your doctor orders a drug that has a requirement to try and fail a different preferred drug first (Step Therapy).
• Your doctor orders a brand version of a drug that has a preferred generic (Generic Substitution). 
  
  • For more information, please see the Generic Medications section below. 

Your doctor knows how to submit information for your authorization request. You can view this information at spbm.medicaid.ohio.gov. 

Prescription drugs

Prescription medications are covered when:

• They are ordered by your provider or another provider treating you or your child. The drug must be listed on the Unified Preferred Drug List. 
• They are ordered or given while you are in an emergency room or hospital.
• They are prescribed by a primary care provider (PCP) or other provider whose services do not need an approval.

Generic medications

Generic drugs have the same ingredients as brand name drugs. To be FDA approved, the generic drug must have the same active ingredient, strength, and dosage (formulation) as the brand name drug. 

If your provider orders a brand name drug and there is a preferred generic available, Gainwell will cover the generic medication. If your provider says that you must have the brand name drug instead of the generic, they must submit a prior authorization request to Gainwell. The request must explain why the preferred medicine will not work for you. Gainwell reviews prior authorizations on an individual basis and thinks about your needs. 

Member Handbook

Your Molina Member Handbook tells you what you need to know about your Molina Healthcare of Ohio Medicaid Health Plan. Read more.

Resources

View the current Unified Preferred Drug List (UPDL)
View the Unified Preferred Drug List (UPDL) Updates for the Current Quarter (30-Day Change Notice)