Upcoming Changes to Molina Dual Options MI Health Link Medicare-Medicaid Plan s Formulary
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1 Upcoming Changes to Molina Dual Options MI Health Link Medicare-Medicaid Plan s Formulary Molina Dual Options may add or remove drugs from our formulary (preferred drug list) during the year. When changes are made, you will receive notice at least 60 days before they occur. These changes include: Removing drugs from our preferred drug list. Adding prior authorization criteria Adding quantity limit restriction When certain changes are made, we act quickly to remove the drug from our preferred drug list. You will receive notice when: The FDA determines that a drug on our drug list is unsafe The drug s manufacturer removes the drug from the market The table below shows the changes that will be coming soon to our preferred drug list. These changes may impact you. Name of Affected AMINOSYN II INJ 7% BROMFENAC OPHTH SOLN 0.09% BUPHENYL TAB 500MG CLINDAMAX GEL 1% COPAXONE INJ 40MG/ML DIDANOSINE CAP 125 MG DOCEFREZ INJ 20MG Description for Change Reason for Change Alternative AMINOSYN-HBC INJ 7% Alternative Copay* Effective Date Tier 2 3/1/2018 BROMFENAC SODIUM OPHTH SOLN 0.09% (ONCE-DAILY) Tier 1 3/1/2018 SODIUM PHENYLBUTYRATE TAB 500 MG Tier 2 6/1/2018 CLINDAMYCIN PHOSPHATE GEL 1% Tier 1 3/1/2018 GLATIRAMER INJ 40MG/ML Tier 2 6/1/2018 VIDEX EC CAP 125MG Tier 2 5/1/2018 DOCETAXEL INJ 80MG/4ML Tier 2 3/1/ P a g e
2 Name of Affected ESTRACE VAGINAL CREAM 0.01% GAVILYTE-H KIT GENTAMICIN INJ 10MG/ML ISTALOL OPHTH SOLN 0.5% LORTAB TAB MG LORTAB TAB 5-325MG Description for Change Reason for Change Alternative LORTAB TAB MENOMUNE INJ A/C/Y/W MORPHINE SULATE INJ 15MG/ML NECON TAB 10/11-28 NYATA RELPAX TAB RENVELA PAK RENVELA TAB 800MG ESTRADIOL VAGINAL CREAM 0.01% Alternative Copay* Effective Date Tier 1 6/1/2018 GAVILYTE-G SOL Tier 1 3/1/2018 GENTAMICIN INJ 40MG/ML Tier 1 5/1/2018 TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE-DAILY) Tier 1 6/1/2018 HYDROCODONE- ACETAMINOPHEN TAB MG Tier 1 3/1/2018 HYDROCODONE- ACETAMINOPHEN TAB MG Tier 1 3/1/2018 HYDROCODONE- ACETAMINOPHEN TAB MG Tier 1 3/1/2018 MENACTRA INJ Tier 2 3/1/2018 MORPHINE SULFATE IV SOLN PF 10 MG/ML Tier 2 3/1/2018 NECON TAB 7/7/7 Tier 1 3/1/2018 NYSTATIN POW Tier 1 4/1/2018 ELETRIPTAN TAB Tier 1 6/1/2018 SEVELAMER CARBONATE PACKET Tier 1 6/1/2018 SEVELAMER CARBONATE TAB 800 MG Tier 1 6/1/ P a g e
3 Name of Affected REYATAZ CAP SABRIL PACK 500MG SUSTIVA CAP 200MG SUSTIVA CAP 50MG TAMIFLU SUSP 6MG/ML TRANSDERM-SC PATCH 1.5MG TRIKLO CAP 1GM TRISENOX SOL 10MG/10ML VIGAMOX DROPS 0.5% ZAZOLE CREAM 0.8% ZIAGEN SOLN 20MG/ML ZOLEDRONIC INJ 4MG Description for Change Reason for Change Alternative Alternative Copay* Effective Date ATAZANAVIR CAP Tier 2 6/1/2018 VIGABATRIN POWDER PACK 500MG Tier 2 6/1/2018 EFAVIRENZ CAP 200 MG Tier 2 6/1/2018 EFAVIRENZ CAP 50 MG Tier 1 6/1/2018 OSELTAMIVIR PHOSPHATE SUSP 6 MG/ML Tier 1 6/1/2018 SCOPOLAMINE PATCH Tier 2 6/1/2018 OMEGA-3-ACID ETHYL ESTERS CAP 1 GM Tier 1 3/1/2018 TRISENOX INJ 12MG/6ML Tier 2 5/1/2018 MOXIFLOXACIN HCL OPHTH SOLN 0.5% Tier 1 6/1/2018 TERCONAZOLE VAGINAL CREAM 0.8% Tier 1 3/1/2018 ABACAVIR SOLN 20MG/ML Tier 1 6/1/2018 ZOLEDRONIC INJ 4MG/5ML Tier 1 3/1/2018 You should work with your doctor to determine if the alternative drug we listed is right for you. If you or your doctor believes the drug affected is medically necessary and you need to continue taking it, you have the right to request an exception. To request an exception call member services at (855) TTY/TDD users should call 711. We are available Monday - Friday, 8:00 a.m. to 8:00 p.m., EST. Molina Dual Options MI Health Link Medicare-Medicaid Plan is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. You can get this information for free in other formats, such as large print, braille, or audio. Call (855) , TTY/TDD: 711, Monday - Friday, 8 a.m. to 8 p.m., EST. The call is free. 3 P a g e
4 Limitations, restrictions, and patient pay amounts may apply. This means that you may have to pay for some services and that you need to follow certain rules to have Molina Dual Options pay for your services. For more information, call Molina Dual Options Member Services or read the Molina Dual Options Member Handbook. Benefits may change on January 1 of each year. The List of Covered s and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. 4 P a g e
5 Molina Healthcare of Michigan (Molina) complies with all Federal civil rights laws that relate to healthcare services. Molina offers healthcare services to all members without regard to race, color, national origin, age, disability, or sex. Molina does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This includes gender identity, pregnancy and sex stereotyping. To help you talk with us, Molina provides services free of charge: Aids and services to people with disabilities Skilled sign language interpreters Written material in other formats (large print, audio, accessible electronic formats, Braille) Language services to people who speak another language or have limited English skills o Skilled interpreters o Written material translated in your language o Material that is simply written in plain language If you need these services, contact Molina Member Services at (855) ; TTY/TDD: 711, Monday - Friday, 8 a.m. to 8 p.m., EST. If you think that Molina failed to provide these services or treated you differently based on your race, color, national origin, age, disability, or sex, you can file a complaint. You can file a complaint in person, by mail, fax, or . If you need help writing your complaint, we will help you. Call our Civil Rights Coordinator at (866) , or TTY, 711. Mail your complaint to: Civil Rights Coordinator 200 Oceangate Long Beach, CA You can also your complaint to civil.rights@molinahealthcare.com. Or, fax your complaint to (562) You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaint forms are available at You can mail it to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C You can also send it to a website through the Office for Civil Rights Complaint Portal, available at If you need help, call ; TTY
6 English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 711(. H7844_17_17035_467_MIMMPMultiLang Accepted 9/5/ MMP0916
7 Hindi ध य न द : यदद आप द द ब लत त आपक ललए म फ त म भ ष स यत स व ए उपलब ध (TTY: 711) पर क ल कर Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Portugués ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). French Creole ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711 ) まで お電話にてご連絡ください Albanian KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). Bengali লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: 711) Serbo-Croatian OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). Syriac (Assyrian language) ܐ ܡ ܓ ܢ ܐܝ ܬ. ܩܪܘ ܢ ܥ ܠ ܡ ܢܝ ܢ ܐ ܕܗ ܝ ܪܬ ܐ ܒܠ ܫ ܢ ܐ ܢ ܠ ܫ ܢ ܢ ܟ ܐ ܗ ܡܙ ܡܝ ܬܘ ܐ : ܐ ܢ ܐ ܚܬܘ ܙܘ ܗ ܪ (TTY: 711) ܝ ܐ ܡ ܨܝ ܬܘ ܢ ܕܩ ܒܠܝ ܬܘ ܢ ܐ ܬܘܪ ܚ ܠܡ ܬ ܐ H7844_17_17035_467_MIMMPMultiLang Accepted 9/5/ MMP0916
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