Prescription Drugs & Medication
Molina Healthcare covers all medically necessary Medicaid-covered medications. We also use a preferred drug list (PDL). These are the drugs that we prefer our provider...
Please click on a form below to view a PDF printable version.
Prior Authorization
Medical Benefit (HCPCS/J-Code) Drug Prior Authorization Request Form
Synagis Prior Authorization form 2020-20...
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The files below are in PDF format ()
Claims
Provider Dispute Resolution Request Form
Prior Authorizations
Behavioral Health Prior Au...
Appeals
Grievance Consent Form
Provider Appeal Form
Behavioral Health
Behavioral Health Prior Authorization Form
Combined MCE Behavioral Health Provider Primary Care Provider Communication For...
Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us.
Authorizations / Utilization Management Forms
Prior Auth LookUp Tool
Prior Authorizatio...
Prior Authorization Forms and Codification Matrix
Prior Authorization Guide/Authorization Form
Prior Authorization Form Private Duty/Attendant Nursing Care
Codification Matrix
J-Code Prior Aut...
Please click on a form below to view a PDF printable version.
The files below are in PDF format ()
Provider Contracting
Contract Request Form
Provider Demographics
Change of Information Form
P...
