» » Molina Healthcare Prior (Rx) Authorization Form

Molina Healthcare Prior (Rx) Authorization Form

In order to request coverage for a patient’s prescription, it may be necessary for the physician in question to submit a Molina Healthcare Prior Authorization Form. It should be noted that the medical office will need to provide justification for requesting the specific medication, and that authorization is not guaranteed. We have provided all of the necessary forms and contacts below.

Fax to:

  • California:
  • Florida:
  • Illinois:
  • Michigan & Wisconsin:
  • New Mexico (Medicaid):
  • New Mexico (Medicare):
  • Ohio:
  • South Carolina:
  • Texas (Medicaid): / Pharmacy:
  • Texas (Medicare): / Pharmacy:
  • Utah:
  • Washington:

Phone:

  • California:
  • Florida:
  • Michigan:
  • Wisconsin:
  • Ohio:
  • Utah:
  • Washington:

By State

How to Write

Step 1 – Write the date.

Step 2 – Enter the patient’s full name, member ID number, and date of birth.

Step 3 – Enter the physician’s full name, phone number, fax number, specialty, and NPI/DEA number.

Step 4 – Provide the name, the strength, and the dose of the medication. Next, provide the quantity of the medication per month, the directions for use, and the duration of use.

Step 5 – In the Diagnosis/Medical Indications field, write the relevant diagnosis of the patient.

Step 6 – In Medical Justification, write the reasons for which you are requesting this coverage.

Step 7 – Beneath Previous Meds Trial – Dates of Use, indicate which previous medication(s) the patient has been prescribed for this condition and the beginning and end dates of the trial.

Step 8 – Next, you must indicate your Pharmacy Fax Number where indicated.

Step 9 – If you have any additional Comments that are relevant to this case, include them in the indicated field.



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