Molinalogo

Molina Healthcare members do not have to pay co-payments or other charges for medical services. If you receive a bill from a provider:

• Check to see if the bill shows if you are being asked to pay charges. If it does, call Member Services. We will help you.


• If the information you get from a provider does not show you need to pay charges, it means you received a statement. A statement is not a bill. The provider is letting you know that your insurance company has been billed for the services provided. It might say “this is not a bill” on the page.


• If you did not receive the services listed in the statement, please call Member Services.


• A provider may ask you to sign a waiver stating that you agree to be responsible for non- covered services.

Let your County Department of Job and Family Services (CDJFS) caseworker know if there are any updates to your address, phone number, email address, other insurance coverage or if you are pregnant or have a newborn baby. You can find your local CDJFS office’s phone number here.

You can tell Molina about changes by updating your information online at MyMolina.com or by calling Member Services.

It is important that you carry your Member ID Card at all times. Your Member ID Card allows you to get your covered services. Show your Member ID Card each time you get services. This includes:

• Seeing your primary care provider (PCP) or other providers
  
  
• Visiting the emergency room
  
  
• Going to an urgent care facility
  
  
• Going to a hospital
  
  
• Getting medical supplies
  
  
• Getting a prescription
  
  
• Getting medical tests

Go to the Member ID Card page to see a sample member ID card and to find out how to replace your card if you lose it.

If you have other health insurance coverage, it is important to tell Molina Healthcare and your CDJFS caseworker.

You will not lose your health coverage for sharing information about your other insurance. Sharing your health insurance information will help your providers and the insurance companies work together to provide your health care. This is called coordination of benefits.

Every time you visit your provider’s office, hospital, or pharmacy, make sure you present all your health insurance ID cards.

Molina Healthcare contracts with primary care providers (PCPs), specialists and pediatricians all over Ohio. These are called our network providers. We want you to have as few changes as possible when you join Molina Healthcare. If your doctor is not in our network, we will help you find other high-quality providers that can meet your needs. View our Provider Directory to see if your health care providers are part of our provider network.

If your PCP’s office is closed or you cannot be seen right away, you may go to an urgent care center or CVS Minute Clinic. Visit our Provider Directory to find an urgent care center in your area.

If you are not sure where to go for care, call our 24-hour Nurse Advice Line for help at (888) 275-8750.

If you have an emergency, call 911 or go to the nearest emergency room. Emergency care is provided when a medical problem is so serious that it must be treated right away. Members can go to any emergency room without a referral or prior authorization for emergency treatment.

Call Poison Control at (800) 222-1222 to get help for a poisoning. Call 911 if a person collapses, has a seizure, can’t breathe, or won’t wake up.

Most services are available to you without prior approval (PA). Some services do require PA.

If a service requires PA, your provider must ask Molina to approve the treatment or service before you can get it. Molina’s medical staff and your doctor review the medical need for your care. They will make sure it is the right care for your specific condition. This process helps keep you safe and healthy.

To find out if a benefit or service requires PA, view your Member Handbook.

Prior approval is also sometimes called prior authorization.

If a service is denied coverage by Molina Healthcare, you can make an appeal within 60 days in one of four ways:

• Call Member Services
  
  
• Fax (888) 295-4761
  
  
• Tell your Care Manager
  
  
• Send us a letter at
  
  Molina Healthcare of Ohio
  
  Attn: Grievance and Appeals Unit
  
  P.O. Box182273
  
  Chattanooga, TN 37422

Click here to learn more.

As a managed care plan, we cover all medically necessary health care benefits and services that are covered by Ohio Medicaid, This includes your:

• Provider appointments


• Dental and vision care


• Prescription drugs


• Durable medical equipment (DME)


• Treatments needed to receive quality care for your medical conditions


• 24-hour Nurse Advice Line


• Transportation

We also help to remove barriers to getting your services and consider your needs as we work toward healthier outcomes. View “What’s Covered” to learn more about benefits and services.

Yes. Molina Healthcare provides vision care to members. View the Vision page for details on covered vision services.

Yes. Molina Healthcare provides an extra transportation benefit to help you get to medically necessary doctor visits and other health resources. View the Transportation page for details on the benefit coverage and how to schedule transportation.

Emergency transportation provided through the “911” emergency response system is covered when medically necessary. This includes emergency ambulance transport services.

Molina Healthcare covers mental health and substance use disorder treatment services. Members may self-refer to community mental health centers for any services they may need. If you prefer to see a private provider, you may choose a behavioral health provider within Molina’s network. Go to the Behavioral Health page for details on covered services.

As a member of Molina Healthcare, you can get the medication that you need from the Single Pharmacy Benefit Manager, Gainwell. For some medications, you will need to get prior authorization. You have no copays or out of pocket costs for prescription drugs.

To find out what drugs are covered under your plan, view the Unified Preferred Drug List for Ohio Medicaid members

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 24 hours a day, 7 days a week.

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

If you find out that your drug is not on the list, call Gainwell at (833) 491-0344 24 hours a day, 7 days a week. Ask them to make sure that your drug is not on the Unified Preferred Drug List (UPDL). If they say it is not on the list, ask your doctor if you can switch to another drug that ODM covers. Give your doctor a list of the drugs ODM pays for. Your doctor may find another drug on the list that treats your medical condition the same way. To get a copy of the list, call Member Services or review the Unified Preferred Drug List here.

Gainwell will work with you to find a drug that meets your needs. If a drug is not on the UPDL, your doctor must send a prior authorization request to Gainwell. Gainwell will review your doctor’s reason for prescribing the drug that is not on the list. If Gainwell approves it, ODM will pay for your drug.

The drugs on this list are chosen by a committee made up of doctors and pharmacists. They are from the Ohio Department of Medicaid Pharmacy & Therapeutics Committee with feedback from the managed care plans. The committee reviews the list every three months and decides which drugs should be on the list. The drugs chosen are the ones that will serve you best.

The committee also reviews FDA (Food and Drug Administration) reports. These reports talk about new drugs the FDA says are okay for use. They also talk about how well current drugs work. The reports help them know if they should add drugs to the list or take some off.

There are certain services you should get from a network pharmacy. They help you know how to take your medicine the safe and healthy way.

When you go to a network pharmacy:

• You should expect to be asked if you want to speak with a pharmacist. This is called a patient consult.


• During a consult you can ask the pharmacist:


• How to take your medicine.


• When you should take it. For example, you might need to take it with or without food.


• How to take your drug the safe way.


• During the consult, the pharmacist may tell you:


• What the drug is for and how it works.


• Side effects the drug may cause.


• How to store the drug. Some drugs must be kept at a certain temperature or in a certain light so they won’t be ruined.


• About any other drugs you should not take. Sometimes when two drugs are taken together, it can be dangerous for you or can stop your medicine from working. Ask your pharmacist about any drug interactions.


• You can also ask for a medication profile review. This is when a pharmacist checks the computer for all of the drugs you are taking. You will be told the best way to take each one throughout the day. The pharmacist will also make sure it is safe for you to take the drugs together during the day. If you take any vitamins or herbal remedies, now is the time to tell your pharmacist. Your pharmacist will let you know if it is okay to take them with your other drugs.


• Ask if your language (of choice) can be put on the Rx bottle. Also ask if the directions for how to take the drug can be written in your language.


• During flu season, some of the network pharmacies may offer flu shots for you as a Molina Healthcare member free of charge. Ask if your pharmacy offers flu shots for Molina Healthcare members.

You should expect these services from your pharmacy. Be sure to use the benefits your pharmacy offers. Gainwell only chooses network pharmacies that serve you best. Gainwell works with their network pharmacies to keep you safe and healthy.