Forms
Here you can find all your provider forms in one place. If you have questions or suggestions, please contact Provider Services at (844) 236-1464.
- Authorizations/Utilization Management
Prior Authorization Requests
NEW FAX FOR PRIOR AUTH SUBMISSIONS: Utilization Management Fax: (877)319-6828
Prior Authorization Code Lists
Prior Authorization Reconsiderations and Appeals
- Claims Forms
Once complete, please fax form to Molina Healthcare of Iowa Appeals and Grievances at 1-855-275-3082.
- Provider Network Forms
- Pharmacy Forms
- 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
- 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
- Tasimelteon Hetlioz PA Form
- Testosterone Products 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
- Women’s Health Services