Molina Healthcare Medication Prior Authorization/Exceptions Request Form 2019-2025 free printable template

Molina Healthcare of Florida Medication Prior Authorization / Exceptions Request Form Fax: (866) 2368531 To ensure a timely response, please fill out form COMPLETELY and LEGIBLY. An incomplete form

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How to fill out Molina Healthcare Medication Prior Authorization/Exceptions Request Form

1. Obtain the Molina Healthcare Medication Prior Authorization/Exceptions Request Form from the Molina Healthcare website or your healthcare provider.
2. Fill in the patient's information, including their name, date of birth, and insurance details.
3. Enter the prescribing physician's information, including name, contact number, and NPI number.
4. Provide the specific medication name, dosage, and frequency requested.
5. Include details about the patient's medical history and the reason for the medication request.
6. Attach supporting documents such as previous medication trials, lab results, or medical notes if required.
7. Review the completed form for accuracy and completeness before submission.
8. Submit the form via the preferred method outlined by Molina Healthcare, usually by fax or email.

Who needs Molina Healthcare Medication Prior Authorization/Exceptions Request Form?

1. Patients who require medication that is not covered by their current plan can ask their healthcare provider to submit this form.
2. Healthcare providers who seek prior authorization for prescription medications on behalf of their patients must complete this form.
3. Pharmacies may require this form when processing prescriptions that need prior authorization.

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What is Molina Healthcare Medication Prior Authorization/Exceptions Request Form?

The Molina Healthcare Medication Prior Authorization/Exceptions Request Form is a document used to request pre-approval for specific medications that require prior authorization before being dispensed or covered by insurance.

Who is required to file Molina Healthcare Medication Prior Authorization/Exceptions Request Form?

Typically, healthcare providers, such as doctors or pharmacists, are required to file the Molina Healthcare Medication Prior Authorization/Exceptions Request Form on behalf of the patient.

How to fill out Molina Healthcare Medication Prior Authorization/Exceptions Request Form?

To fill out the form, the healthcare provider must provide patient information, details about the medication, diagnosis, and any necessary clinical information to support the request.

What is the purpose of Molina Healthcare Medication Prior Authorization/Exceptions Request Form?

The purpose of the form is to facilitate the evaluation of medication requests to ensure the prescribed therapy is appropriate and meets clinical criteria for coverage.

What information must be reported on Molina Healthcare Medication Prior Authorization/Exceptions Request Form?

The form must report patient demographics, insurance information, medication details (including dosage and duration), diagnosis, and any relevant clinical notes or previous treatment history.