Pharmacy

For Pharmacy forms, please go to our forms page

Preferred Drug List

Please familiarize yourself with the Preferred Drug List as you prescribe medications for Molina Healthcare beneficiaries. Thank you for your cooperation.

icon Preferred Drug List. Also available is the machine-readable JSON file 

 

Prior Authorizations

Molina’s decisions are based upon the information included with the PA request. Clinical notes are recommended.

icon Pharmacy Prior Authorization Form

icon Real-Time Prescription Benefits Access and Onboarding Handbook 

icon  Real-Time Prescription Benefits Information at the Point of Care

 

Prior Authorization Criteria:

Actemra

Acthar Gel

Adakveo

Adbry

Adcetris

Aduhelm

Adzynma

Agamree

Aldara_Zyclara

Alpha-1 Antitrypsin Deficiency Enzyme

Amondys 45

Ampyra

Amvuttra

Antidiabetic Agents

Antiemetics

Antimalarial Agents

Aphexda

Apokyn, Kynmobi

Arcalyst

Arixtra

Azactam

Baxdela

Benlysta

Beovu

Bimzelx

Botulinum Toxin

Brineura

Briumvi

Brixadi

Bylvay

Cablivi

Calcitonin Gene-Related Peptide Antagonist

Camzyos

Cancidas

Carisoprodol Products

Cayston

Cerdelga

CGM Molina

CGRP Antagonists

Chemet

Cholbam

Cialis - BPH Coverage Only

Cibinqo

Cimzia

Cinqair

Constipation Agents

Cosela

Cosentyx Molina

Crysvita

Cubicin

Cuvposa Oral Solution

Cystic Fibrosis

Cytogam

Dalvance

Daraprim

Daybue

Desmopressin Nasal and Oral _ DDAVP

Dextenza

Dexycu

Diabetic Testing Supplies

Diclegis_Bonjesta

Diclofenac Topical

Direct Oral Anticoagulants

Disposable Insulin Delivery Device

Doptelet

Dry Eye Therapies

Dupixent

Duplication of Therapy_High Risk Combination

Durysta

Egrifta SV

Elaprase

Elfabrio

Eltrombopag

Empaveli

Enbrel

Endari

Enjaymo

Enspryng

Entyvio

Enzyme Replacement Therapy for Gaucher Disease_Cerezyme_Elelyso_Vpriv

Enzyme Replacement Therapy for Lysosomal Storage Disorders_Aldurazyme, Naglazyme

Eohilia_budesonide oral susp

Erythropoiesis-stimulating agents_ESAs

Esbriet

Evenity

Evkeeza

Evrysdi

Exondys 51

Eylea

Fabhalta

Fabrazyme

Fasenra

Fentanyl

Filgrastim

Filspari

Filsuvez

Firdapse

Forteo

Furoscix

Fuzeon

Galafold

Gamifant

Gattex

Gender Dysphoria Hormone Therapy

Givlaari

Global Compounded Product

Global Formulary Exception Criteria_NF_QL_ST_etc.

Gocovri_Osmolex

Growth Hormone

Hemophilia and Blood Factor Products

Hemostatic Agents

Hep B Immune Globulin

Hepatitis C

Hereditary Angioedema Agents

High Cost Outlier Targeted Drug Exception

Humira Molina

Hyaluronic Acid Injections

iDose TR

Igalmi

Ilaris

Ilumya

Iluvien

Imcivree

Immunoglobulin_SCIg_IVIg

Increlex

Infliximab

Inpefa sotagliflozin

InPen

Inrebic

Insulin Patch

Intravenous Bisphosphonates

Iron Chelating Agents_Desferal_Exjade_Ferriprox_Jadenu

Iron Deficiency Anemia Agents

Isotretinoin

Isturisa

Izervay

Jakafi

Jesduvroq

Joenja

Juxtapid

Kanuma

Kerendia

Keveyis

Kevzara

Kineret

Korlym

Korsuva

Koselugo

Krystexxa

Kuvan

Lamzede

Lemtrada

Leqembi

Leqvio

Leukine

Leuprolide long-acting

Linezolid

Litfulo

Livmarli

Livtencity

Lucemyra

Lucentis_Byooviz

Lumizyme

Lupkynis

Medical Necessity Review

Mepron

Mepsevii

Mozobil

Mulpleta

Myalept

Mycamine

Nasal Steroids

Natpara

Nexletol - Nexlizet

NexoBrid

Nexviazyme

Nitisinone

Northera

Nplate

Nucala

Nuedexta

Nulibry

Nulojix

Nuzyra

Ocaliva

Ocrevus

Octreotide

Ofev

Off-Label Use of Drugs and Biologic Agents

Ojjaara

Olumiant

Omega-3 Fatty Acids

Omvoh

Onpattro - Tegsedi

Opfolda

Opioids

Opzelura

Orencia

Orgovyx - Myfembree

Orladeyo

Otezla

Otrexup Rasuvo Reditrex

Oxbryta

Oxervate

Oxlumo

Palforzia

Palynziq

Parsabiv

Penicillamine - Trientine

Pombiliti

Prescription Compounded Product

Prevymis

Procysbi, Cystagon

Prolia

Promacta

Pulmicort Respules

Pulmonary Arterial Hypertension

Pulmozyme

Pyrukynd

Qalsody

Qutenza

Radicava

Ranibizumab and Biosimilars

Ravicti

Reblozyl

Rebyota

Recorlev

Regranex

Relizorb

Relyvrio

Retisert, Yutiq Intravitreal Implant

Revcovi

Rezurock

Riluzole

Rinvoq

Rituxan and Biosimilars

Rivfloza

Rolvedon, Neulasta, and Related Biosimilars

Rozlytrek

Ryplazim

Rystiggo rozanolixizumab

Santyl

Saphnelo

Sensipar

Seysara

Signifor

Siliq

Simponi-Simponi Aria

Sivextro

Skyclarys

Skyrizi

Sohonos

Soliris _ Ultomiris

Sotyktu

Spevigo

Spiriva

Stadol

Standard Oncology Criteria

Stelara

Strensiq

Sublocade

Sunlenca

Sunosi

Susvimo Intravitreal Implant

Syfovre

Synagis

Synarel

Tadalafil and combinations

Taltz

Tarpeyo

Tavalisse

Tavneos

Tepezza

Testosterone

Tezspire

Thiola

Tobramycin for inhalation

Tolvaptan

Topical Antibacterials

Tremfya

Triptodur

Trogarzo

Tymlos

Tysabri

Tzield

Uplizna

Vabysmo

Valcyte

Vancocin Capsules

Veklury

Velsipity

Veopoz

Veozah

Verquvo

Vibativ

Vibrant

Vijoice

Viltepso

Vimizim

Vitrakvi

Vonjo

Vowst

Voxzogo

Vtama cream

Vyndaqel _ Vyndamax

Vyondys 53

Vyvgart

Wainua

Xacduro

Xeljanz-Xeljanz XR

Xenazine

Xenpozyme

Xermelo

Xgeva

Xiaflex

Xipere

Xolair

Xphozah

Zavesca

Zemplar

Zilbrysq

Zilretta

Zinplava

Zokinvy

Zortress

Zoryve Cream

Zovirax Topical

Ztalmy

Zulresso

Zurzuvae

Step Therapy

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.