Molinalogo

Prior Auth LookUp Tool

Prior Authorization Requests

Utilization Management Fax: (877) 319-6828

Universal Prior Authorization:

• Medicaid Supplemental Information PA Form
• Inpatient Medicaid Prior Authorization Form
• Outpatient Medicaid PA Form
  

Iowa Medicaid Resources

Iowa HHS Provider Forms

Please download these guides for Molina fax information:

Inpatient Medicaid PA Resource Guide

Outpatient Medicaid PA Resource Guide

Prior Authorization Code Lists

• Prior Authorization (PA) Code List – Effective 4/1/2023

Prior Authorization Reconsiderations and Appeals

• Appeal Representative Authorization
• Member Appeal Form
• Member Appeal Form with AOR Form

Overpayment Dispute Form
Provider Early Reversal Permission Form

• Abilify Mycite PA Form
• ACL Inhibitors PA Form
• Acute Migraine Treatments PA Form
• Adbry PA Form
• Age Edit Override Codeine Tramadol PA Form
• Alpha-1 Proteinase Inhibitors PA Form
• Ampyra PA Form
• Amylino Mimetic PA Form
• Antidepressants PA Form
• Antidiabetics Noninsulin PA Form
• Antiemetic Products PA Form
• Anti-Fungal PA Form
• Antihistamines PA Form
• Apremilastotezla PA Form
• Baclofen PA Form
• Bed PA Form
• Benzodiazepines PA Form
• Biologicals Arthritis PA Form
• Biologicals Axial Spondyloarthritis PA Form
• Biologicals HS PA Form
• Biologicals IBD PA Form
• Biologicals Plaque Psoriasis PA Form
• Bronchitol PA Form
• Bylvay PA Form
• Bystolic PA Form
• Camzyos PA Form
• Cholbam PA Form
• CNS Stimulants Atomoxetine PA Form
• CNS Stimulants PA Form
• Ivabradine Corlanor PA Form
• Cystic Fibrosis Agents Oral PA Form
• Deferasirox Exjade PA Form
• Doac PA Form
• Dojolvi PA Form
• Dupixent PA Form
• Duplicate Therapy Edit PA Form
• Emflaza PA Form
• Empaveli PA Form
• Enspryng PA Form
• Erythropoiesis-Stimulating Agents PA Form
• Eucrisa PA Form
• Evrysdi PA Form
• Extended-Release Formulation PA Form
• Febuxostat Uloric PA Form
• Fentanyl Short Acting Products PA Form
• Fifteen Day Supply Override PA Form
• GLP-1 Agonist Basal Insulin Combination PA Form
• GnRH Receptor Antagonist Oral PA Form
• Granulocyte Colony Stimulating Factor PA Form
• Growth Hormone PA Form
• Hematopoietic Chronic ITP PA Form
• Hepatitis C Treatments PA Form
• High Dose Opioids PA Form
• IL-5 Antagonists PA Form
• Initial Days Supply Limit Override PA Form
• Isotretinoin Oral PA Form
• Janus JAK Inhibitors PA Form
• Kerendia PA Form
• Ketorolac PA Form
• Kuvan PA Form
• Lidocaine Patch PA Form
• Livmarli PA Form
• Long-Acting Opioids PA Form
• Lupron Depot Adult PA Form
• Lupron Depot Pediatric PA Form
• Methotrexate Injection PA Form
• Mifepristone Korlym PA Form
• Miscellaneous PA Form
• Modified Formulations PA Form
• Muscle Relaxants PA Form
• Naloxone Nasal Spray PA Form
• New Market Drugs PA Form
• Nocturnal Polyuria Treatments PA Form
• Non-biologic Agents Ulcerative Colitis PA Form
• Non-Parenteral Vasopressin Derivatives PA Form
• Non-Preferred Drug PA Form
• NSAID Drugs PA Form
• Nuedexta PA Form
• Ophthalmic Agents Presbyopia PA Form
• Oral Constipation Agents PA Form
• Oral Immunotherapy PA Form
• Oral MS Agents PA Form
• Ospemifene PA Form
• Oxbryta PA Form
• Palforzia PA Form
• Pavilizumab PA Form
• PCSK9 Inhibitors PA Form
• Pirfenidone And Nintedanib PA Form
• Potassium Binders PA Form
• Prevymis PA Form
• Proton Pump Inhibitors PA Form
• Pulmonary Arterial Hypertension Agents PA Form
• Qelbree PA Form
• Quantity Limit Override PA Form
• Rayaldee PA Form
• Regranex PA Form
• Repository Corticotropin Injection PA Form
• Roflumilast Daliresp PA Form
• Sedative/Hypnotic Non-Benzodiazepine PA Form
• Select Anticonvulsants PA Form
• Selected Brand Name Drug PA Form
• Select Oncology Agents PA Form
• Select Preventative Migraine Treatments PA Form
• Short-Acting Opioids PA Form
• Sodium Oxybate Products PA Form
• Sotyktu PA Form
• Tasimelteon Hetlioz PA Form
• Testosterone Products PA Form
• Tezspire PA Form
• Topical Acne & Rosacea PA Form
• Topical Antifungals PA Form
• Topical Corticosteroids PA Form
• Topical Immunomodulators PA Form
• Verkazia PA Form
• Verquvo PA Form
• Viberzi PA Form
• Vijoice PA Form
• Vitamins, Minerals and Multiple Vitamins PA Form
• VMAT 2 Inhibitors PA Form
• Vorapaxar Zontivity PA Form
• Vusion Ointment PA Form
• Xolair PA Form
• Xifaxan PA Form
• Zurampic PA Form
• Zyvox PA Form

• Pregnancy Notification Form