Providers can find details about Molina’s prior authorization (PA) process, methods for submitting requests, procedures for denials and peer-to-peer reviews, as well as how to access forms and contact our team.
Important update for providers:
Starting 2/1/26, providers must submit medical benefit PA requests through our Availity provider portal, as Molina no longer accepts fax submissions. Continue to follow the current pharmacy submission processes for pharmacy benefit PA requests; do not submit these through our Availity provider portal.
Service Prior Authorizations
Office visits to participating (PAR) providers and referrals to network specialists do not need a PA. Emergency services also do not require authorization.
Molina requires PA for certain services. See which services need PA with the prior authorization lookup tool. Providers can request and manage authorizations via Availity provider portal.
Pharmacy Prior Authorizations
Molina attempts to provide appropriate and cost-effective drug therapy to all members covered by the Molina pharmacy program. If a member requires medication that does not appear on the formulary, the physician can make a request for a non-preferred medication.
For more information on pharmacy prior authorization.
Medicaid
Providers can submit a PA request for drugs not on the drug formulary.
Medicare and Marketplace
Molina manages prescription drug benefits through CVS/Caremark. Outpatient drugs on Molina's Drug Formulary are covered, while medications not on the Drug Formulary need PA for approval. Drugs that require advanced approval for coverage are reviewed against standard rules to determine medical necessity. Providers must show a medically accepted use for the drug and that other treatments have not worked or are not clinically appropriate. Other requirements may apply depending on the drug. We may require certain test results to show a drug is right. A member’s response to drug samples from a provider or a drug maker will not be considered as a reason to bypass standard rules for coverage.