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Prescription medications are covered when: 

• They are ordered by your provider or another doctor treating you or your child and the drug is listed on the Texas Medicaid Formulary.
  • The link above will direct you to a search tool where you can verify if a drug is covered. Please note that the list of covered drugs can change daily.
  • The Texas Medicaid Formulary is a list of approved drugs that doctors can order for you.
• They are ordered or given while you are in an emergency room or hospital.
• They are given while you are in a rest home, nursing home or convalescent hospital.
• They are ordered by a plan doctor for a covered service. You get them through a pharmacy that is in the Molina Pharmacy Network. 

If you cannot leave home, Molina can provide you with mail order pharmacy services. This is done by CVS Caremark. Some pharmacies also have delivery service. Please call Molina Member Services Toll Free at (866) 449-6849. We will tell you how to get mail delivery.

If a drug ordered by your doctor is not covered by the Texas Medicaid Formulary, your doctor can submit a request for exception on your behalf. Your doctor has been told how they can submit information in support of your exception request. You can view this information in the Pharmacy Prior Authorization Forms section on the Molina website.

Molina adheres to the Texas Health and Human Services Commission (HHSC) Vendor Drug Program’s Preferred Drug List (PDL) for Medicaid drugs. HHSC’s website also includes exception criteria for each drug class included on the Medicaid PDL. These exception criteria describe the circumstances under which a non-preferred drug may be dispensed without an exception request. These exception criteria, including but not limited to fail first and clinical guidelines, can be found under the “PDL Criteria Guide” here. Formulary preferred and non-preferred drugs may require Clinical PA. HHSC posts Clinical criteria on their website for each drug class that requires Clinical PA.

The link above also contains information on the following:

• Generic substitution:
  • Generic drugs have the same ingredients as brand name drugs. To be FDA (government) approved, the generic drug must have the same active ingredient, strength and dosage (formulation) as the brand name drug.
• Therapeutic Interchange:
  • Different drugs under the same therapeutic class that have the same effects.
• Limits on your drug coverage including, but not limited to:
  • Refill limits for Medicaid members:
    • Most prescriptions can be filled early when at least 85% of the previous fill has been used.
    • Scheduled (controlled) medications can be filled early when at least 90% of the previous fill has been used.
    • Medicaid members can fill up to a 34-day supply on most medications, unless otherwise specified by the Texas Health and Human Services Commission (HHSC).

Member Handbook
It tells you what you need to know about your STAR Program. You may get value-added services in your area. Read here.

How do members get care?
Call Member Services at (866) 449-6849, Monday to Friday, 8:00 a.m. - 5:00 p.m. 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 Molina Healthcare’s contracted pharmacies within Texas. Prescriptions are covered outside of the state of Texas (out of area) for emergency or urgent services only
• You need an interpreter to communicate with the pharmacy about getting your medication.
• You need more information on your drug benefit like fill limits and the prior authorization process
• When you have an emergency and need drugs, your pharmacy can provide you with up to a 72-hour supply of the drug.

If you are deaf or hard of hearing:
For English call our TTY line at (800) 735-2989 or 711
For Spanish call (800) 662-4954

To view a list of pharmacies, please click here.

To view the Texas Medicaid Formulary, please click here.