Forms
If you have any questions, please contact Member Services .
The following forms may be helpful to you. Go to the appropriate link to download printable copies
Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor
or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would
like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina
Medicare at:
| MAIL: | Molina Medicare | |
| 7050 Union Park Center, Suite 200 | ||
| Midvale, UT 84047. |
Coverage Determination Request Form – Use this form to request coverage for a drug that is not on the formulary (a
formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception)
or reimbursement for a covered drug that you purchased at an out-of-network pharmacy. Complete this form and mail or
fax to:
| FAX: | (866) 290-1309 | |
| MAIL: | Molina Medicare | |
| 7050 Union Park Center, Suite 200 | ||
| Midvale, Utah 84047 |
You may also submit your Coverage determination request form here online.
How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal
Redetermination Form - Use this form to request a redetermination (appeal). Complete this form and mail or fax to:
| Address: | 7050 S Union Park Center Drive Suite 200 | |
| Midvale, Utah 84047 | ||
| Fax: | (866) 290-1309 | |
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You may also submit your Redetermination request form here online.
Pharmacy Direct Member Reimbursement Form - Use this form to request a reimbursement for something you have paid
out of pocket but believe should have been covered by your plan.
Grievance and Appeal forms & the Medicare.gov Complaint Form
*Printed copies of information posted on our website are available upon request.
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