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 2026 Molina One Care (HMO D-SNP)

 

 2026 Molina One Care (HMO D-SNP)

 

Can the Formulary Change?

We may add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from the formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug, and you are taking the drug affected by the change, we will notify you of the change at least 30 days before the date that the change becomes effective. However, if a drug is removed from our formulary because the drug has been recalled from the market, we will not give 30 day notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.

 

For more information on covered drugs and how to fill your prescriptions, including obtaining prescriptions at Out-of-Network Pharmacies (see below) and how to get a temporary supply of drugs as a new member, see Transition Policy (below). You can ask Molina One Care to make an exception to our coverage rules by completing the Coverage Determination Request form or the Drug Determination Request form (see Member Materials & Forms Page).

 

 2026 Molina One Care (HMO D-SNP)

 

 2026 Molina One Care(HMO D-SNP)

 

 2026 Molina One Care (HMO D-SNP)

 2026 Molina One Care (HMO D-SNP)

 2026 Molina One Care (HMO D-SNP)

 

What is prior authorization?

For certain drugs, you or your provider need to get preapproval (or prior authorization) from Molina One Care before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

 

See the Prior Authorization Grid (above) for drugs that require prior authorization.

 

 2026 Step Therapy Grid – Molina One Care (HMO D-SNP)

 2026 Medicare Part B Drug (J-Code) Step Therapy – Molina One Care (HMO D-SNP)

 

What is step therapy?

In some cases, we require that you first try certain drugs to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat the condition but Drug A costs less, you may need to try Drug A first. If Drug A doesn’t work for you, we’ll then cover Drug B.

 

 2026 Molina One care(HMO D-SNP)

 

Medication Therapy Management Program

Can I get help managing my prescriptions (Medication Therapy Management MTM)?

Molina’s Medication Therapy Management (MTM) program is a service provided at no cost. MTM is not considered a benefit and is offered to members that meet certain criteria. A pharmacist or other trained health care provider will review your prescription, over-the-counter (OTC) and supplement/herbal medications with you over the phone or in person at your local pharmacy. The goal of MTM is to help you understand your medicines, resolve side effects and answer questions you may have about your medication.

How do I Qualify for MTM?

Molina determines MTM eligibility on a quarterly basis using medical and pharmacy claims information. You qualify for MTM if you meet each of the three criteria below:

1. Have three or more of the following conditions:

• Alzheimer's Disease
• Bone Disease-Arthritis (including osteoarthritis, osteoporosis, and rheumatoid arthritis)
• Chronic Heart Failure (CHF)
• Diabetes
• Dyslipidemia
• End-stage renal disease (ESRD)
• Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)
• Hypertension
• Mental health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions)
• Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders)

2. Take at least eight maintenance Part D drugs

3. Are likely to incur annual costs for covered Part D drugs equal to or greater than $1,276 in 2026

In addition to the above criteria, you may also qualify if you are taking certain pain management medications.

Once you meet the criteria, you will be automatically enrolled in the MTM program and mailed a letter with information about the program and how to contact us. We may also call you to schedule an appointment to speak with a pharmacist.

 

What is discussed during my MTM consultation?

In the comfort of your own home, a pharmacist or other trained health care provider will help you:

• Review all your prescription, over-the-counter (OTC) and supplement/herbal medicines
• Discuss side affects you may have when taking certain medicines
• Answer questions you have about your medicine
• Suggest potential improvements to your medication regimen
• Make a list of your medicines with when and how you should take them
• Create goals for taking your medicine
• CMR Summary Letter will be mailed to you after conversation

 

MTM is performed over the phone and the appointment will last approximately 30 minutes. After the appointment, you will be mailed a Personal Medication List that you can share with your health care providers. You will also be mailed a Medication Action Plan that summarizes what was discussed during your MTM encounter. If the MTM provider has any concerns about your medications, such as drug interactions, your prescribing doctors will be made aware. We encourage you to participate in this Comprehensive Medication Review at least once a year and if possible, before your annual wellness visit with your doctor.

How do I contact Molina Medicare to participate in MTM?

To participate in the Medication Therapy Management Program, please call (855) 658-0918, TTY/TDD 711, Monday – Friday, 7:00 a.m. – 6:00 p.m., MT.

 

Medicare Prescription Payment Plan

What is the Medicare Prescription Payment Plan?

The Medicare Prescription Payment Plan is a payment option that works with your current drug coverage to help you manage your out-of-pocket costs for drugs covered by your plan by spreading them across the calendar year (January–December). Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option, and participation is voluntary.

If you select this payment option, each month you’ll continue to pay your plan premium (if you have one), and you’ll get a bill from your health or drug plan to pay for your prescription drugs (instead of paying the pharmacy). There’s no cost to participate in the Medicare Prescription Payment Plan.

How does it work?

When you fill a prescription for a drug covered by Part D, you won’t pay your pharmacy (including mail order and specialty pharmacies). Instead, you’ll get a bill each month from your health or drug plan.

Even though you won’t pay for your drugs at the pharmacy, you’re still responsible for the costs. If you want to know what your drug will cost before you take it home, call your plan, or ask the pharmacist.

This payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs. Learn about other programs that might save you money, if you qualify.

How is my monthly bill calculated?

Your monthly bill is based on what you would have paid for any prescriptions you get, plus your previous month’s balance, divided by the number of months left in the year. All plans use the same formula to calculate your monthly payments. Review examples of how this payment option works in different situations.

Your payments might change every month, so you might not know what your exact bill will be ahead of time. Future payments might increase when you fill a new prescription (or refill an existing prescription) because as new out-of-pocket costs get added to your monthly payment, there are fewer months left in the year to spread out your remaining payments.

In a single calendar year (January – December), you’ll never pay more than:

• The total amount you would have paid out of pocket to the pharmacy if you weren’t participating in this payment option.
• The out-of-pocket maximum for prescription drugs that are covered by your plan ($2,100 in 2026).

The prescription drug law caps your out-of-pocket drug costs for covered drugs at $2,100 in 2026. This is true for everyone with Medicare drug coverage, even if you don’t participate in the Medicare Prescription Payment Plan.

Will this help me?

It depends on your situation. Remember, this payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs.

You’re most likely to benefit from participating in the Medicare Prescription Payment Plan if you have high drug costs earlier in the calendar year. Although you can start participating in this payment option at any time in the year, starting earlier in the year (like before September), gives you more months to spread out your drug costs. Answer a few questions to find out if this payment option is likely to help you.

If there’s a drug that you’d like to take but it’s too expensive, and you think this payment option might spread out the cost enough to work for you, contact Member Services to confirm the drug is covered and get more help.

This payment option may not be the best choice for you if:

•   Your yearly drug costs are low.
• Your drug costs are the same each month.
• You’re considering signing up for the payment option late in the calendar year (after September).
• You don’t want to change how you pay for your drugs.
• You get or are eligible for Extra Help from Medicare.
• You get or are eligible for Medicare Savings Program.
• You get help paying for your drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.

Learn about programs that can help lower your costs.

How do I sign up?

There are several ways that you can opt in to participate in this payment option:

• Complete the Medicare Prescription Payment Plan Participation Request Form and mail it to:
  Molina Healthcare
  Attn: Membership Accounting Department
  P.O. Box 22800
  Long Beach, CA 90801-9945
• Fill out and submit the form directly through MyMolina:
  •  Log into the portal
  • Go to “My Plan Resources"
  • Click the “Helpful Links” tab
  • Go to “Medicare Prescription Payment Plan"
  • Fill out the form and submit
• Call Member Services at (833) 775-1735 (TTY: 711) and a representative can help you complete the form over the phone. We are available October 1 – March 31, 8 a.m. to 8 p.m. local time, 7 days a week. From April 1 – September 30, Monday – Friday, 8 a.m. to 8 p.m. local time.

What happens after I sign up?

If you are new to the plan, we will process your request within:

• 10 calendar days of receipt of your election form.
• If your enrollment in our plan will start sooner than 10 days from when we receive your election form, we will process your election before your enrollment in our plan starts so that you will be enrolled in the program on the same day that your plan starts.

If you are currently a member:

• We will process your request within 24 hours, but enrollment will be effective on the date we receive your completed request.
• If you paid any cost-share for an urgently needed prescription before we processed your election, we may make your election effective before we receive it. This can happen if you meet the following criteria:
  • You believe that taking 24 hours to process your request may seriously jeopardize your life, health, or ability to regain maximum function.
  • You request a retroactive election within 72 hours of the date and time you paid and received your urgently needed prescription.

How do I pay my bill?

After we approve your participation in the Medicare Prescription Payment Plan, you’ll get a letter from Molina Healthcare with information about how to pay your bill.

What happens if I don’t pay my bill?

You’ll get a reminder from your health or drug plan if you miss a payment. If you don’t pay your bill by the date listed in that reminder, you’ll be removed from the Medicare Prescription Payment Plan. You’re required to pay the amount you owe, but you won’t pay any interest or fees, even if your payment is late. You can choose to pay that amount all at once or be billed monthly. If you’re removed from the Medicare Prescription Payment Plan, you’ll still be enrolled in your Medicare health or drug plan.

Always pay your health or drug plan monthly premium first (if you have one), so you don’t lose your drug coverage. If you’re concerned about paying both your monthly plan premium and Medicare Prescription Payment Plan bills, learn about programs that can help lower your costs.

You can call Member Services if you think there is a mistake with your Medicare Prescription Payment Plan bill. If you think there is a mistake, you have the right to follow the grievance process found in your Member Handbook or Evidence of Coverage.

How do I leave the Medicare Prescription Payment Plan?

You can leave the Medicare Prescription Payment Plan at any time by contacting Member Services. Leaving won’t affect your Medicare drug coverage and other Medicare benefits. Keep in mind:

• If you still owe a balance, you’re required to pay the amount you owe, even though you’re no longer participating in this payment option.
• You can choose to pay your balance all at once or be billed monthly.
• You’ll pay the pharmacy directly for new out-of-pocket drug costs after you leave the Medicare Prescription Payment Plan.

What happens if I change health or drug plans?

If you leave your current plan, or change to a new Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage), your participation in the Medicare Prescription Payment Plan will end.

Contact your new plan if you’d like to participate in the Medicare Prescription Payment Plan again.

Where can I get more information?

You can visit Medicare.gov/prescription-payment-plan to see if this payment option might be a good fit for you. You can also call Member Services at (833) 775-1735. We are available October 1 – March 31, 8 a.m. to 8 p.m. local time, 7 days a week. From April 1 – September 30, Monday – Friday, 8 a.m. to 8 p.m. local time. TTY users can call 711.