Items on this list will only be dispensed after prior authorization from Molina Healthcare.
Certain injectable and specialty medications require prior authorization
Drug Specific Policy and Prior Authorization Criteria
Molina Healthcare, Inc. Medical & Drug Policies and Coverage Determination Guidelines Terms and Conditions
Please read the terms and conditions below carefully.
Molina Healthcare, Inc. has developed Medical Clinical Policies (MCP) and Drug Prior Authorization Criteria (RxPA) to assist us in administering drug benefits. These policies and guidelines are intended to be a resource for relevant information about drugs, treatments, and coverage. They do not constitute medical advice.. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.
Our Medical Clinical Policies (MCP) and Drug Prior Authorization Criteria (RxPA) express our determination of whether a health service (e.g., test, device or procedure) have been proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.
Benefit coverage for health services is determined by the member specific benefit plan document, such as Evidence of Coverage, Schedule of Benefits, Member Handbook, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies and guidelines.
Medical Clinical Policies (MCP) and Drug Prior Authorization Criteria (RxPA) are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support Molina Healthcare, Inc. coverage decision making. The information presented in these policies and guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis.
In addition to state and federal guidelines and the MCP and RxPA, Molina Healthcare, Inc. may use evidence-based clinical reviews, algorithms and summaries developed by third parties, such as the McKesson InterQual®, MCG, Hayes Tract Manager or Evicore guidelines that assist Molina Healthcare, Inc. in administering health benefits for medically necessary treatments and procedures. All coverage guidelines and clinical tools are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.
Medical Clinical Policies (MCP) and Drug Prior Authorization Criteria (RxPA) are the property of Molina Healthcare, Inc. Unauthorized copying, use and distribution of this information is strictly prohibited. The McKesson InterQual®, MCG, Hayes Tract Manager or Evicore Guidelines are proprietary to their respective publishers and are not published on this website.
When these policies are used to determine medical necessity, clinical guidelines will be applied in the following order: 1. Applicable Federal mandates and CMS Guidelines: National Coverage Determinations (NCD), Local Coverage Determinations (LCD), 2. State Regulations and State Specific Criteria Guideline Sets 3. Delegated utilization management partner (Evicore) clinical criteria guidelines, 4. Molina Healthcare, Inc. guidance documents and policies, including Molina Clinical Policy (MCP), Molina Clinical Review (MCR) and Drug Prior Authorization Criteria, 5. Third Party licensed proprietary clinical resources: InterQual® Criteria, MCG, American College of Radiology (ACR), 6. National Comprehensive Cancer Network (NCCN) 7. Hayes Technology Assessments. This is applicable to change based on Molina Healthcare, Inc. Policy and Procedure review.
Last Modified 10/9/2019
This policy addresses the use of Xolair (omalizumab) for subcutaneous use for the treatment of moderate to severe persistent asthma and chronic urticaria.
Last Modified 9/11/2019
This policy addresses the use of Avastin (bevacizumab) for the treatment of FDA approved and medically accepted indications.
Last Modified 9/11/2019
This policy addresses the use of Herceptin (trastuzumab) for the treatment of FDA approved and medically accepted indications.
Last Modified 9/11/2019
This policy addresses the use of Perjeta (pertuzumab) for the treatment of FDA approved and medically accepted indications.
This policy addresses the use of Duchene Muscular Dystrophy (DMD) for the treatment of FDA approved and medically accepted indications
Last Modified 4/1/2022
This policy addresses the use of Hepatitis C Antiviral Therapy for the treatment of FDA approved and medically accepted indications.
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