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 formand mail it to Molina Dual Options STAR+PLUS MMP at:
Molina Healthcare of California
200 Oceangate, Suite 100
Long Beach, CA 90802
How to Request Coverage Determination - 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. Ask us for a coverage determination by phone at (866) 856-8699 8:00 a.m. - 8:00 p.m. Monday to Friday, local timeTTY/TDD: 711
Molina Healthcare of Utah
7050 Union Park Center, Suite 200
Midvale, UT 84047
Fax: (866) 290-1309
How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal.
Attn: Grievance and Appeals
P.O. Box 22816
Long Beach, CA 90801-9977
Fax: (866) 771-0117
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.
Medicare.gov Complaint Form
*Printed copies of information posted on our website are available upon request.
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