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Preferred Drug List

Molina Medicare will generally cover any drug listed in our formulary as long as:

	the drug is medically necessary,
	the prescription is filled at a Molina Medicare network pharmacy,
	and other plan rules are followed.

For more information on how to fill your prescriptions, please review your Disclosure Form and Evidence of Coverage.

The links below are in PDF format (), please click on them to download printable copies of the most recent formulary edition:

2008 changes to the Formulary

Abridged Formulary

Comprehensive Formulary

How to file grievances and appeals
(see sections 10, 11, and 12 of the EOC*)

How to File Exceptions

Out of Network Coverage

Can the Formulary Change?

	Forms:
	Appointment of Representative Form (CMS-1696)**
	Coverage Determination Request Form
	Drug Authorization Request Form
	Drug Determination Request Form
	2009 Prior Authorization Grid
	Enrollment Form and Instructions

Requesting a grievance report:

When you ask for it, the government requires Molina Healthcare, Inc. to provide you with reports that describe what happened to formal complaints that our product, Molina Medicare received from our Medicare members. There are two types of formal complaints: Appeals and Grievances. Medicare members have a right to file an appeal or grievance with their Medicare health plans. An appeal is a formal complaint about Molina Medicare's decision not to pay for, not to provide, or to stop an item or service that a Medicare member believes s/he needs.

Each Medicare health plan will have different numbers of appeals and quality of care grievances, and these numbers can mean different things. For example, a Medicare health plan might have a small number of appeals and quality of care grievances because the plan talks with members about their concerns and agrees to find solutions. You may contact the plan and ask for a summary report of the number of grievances and appeals received and what happened to those complaints over a specific period of time.

Transition Process

Changes to our Medicare Part D formulary
Molina Medicare may make changes to our formulary during the year.

If we remove drugs from our formulary, or add restrictions we must let our members know at least 60 days before the effective date.

Molina Medicare is an organization with a Medicare contract. This contract is renewed annually, and coverage beyond the end of the contract year is not guaranteed.

** An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.If you would like to appoint a representative please reference the CMS Appointment of Representation form (Form CMS-1696). You and your appointed representative must complete this form and mail it to Molina options plus at
Molina Medicare
7050 Union Park Center, Suite 200
Midvale, UT 84047

You will need the free Adobe Acrobat Reader to read this file.

*EOC = Evidence of Coverage 2007 (2008 EOC coming soon)

Last Updated 11/19/2008 Pending CMS Approval
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