Prior Authorization Request Procedure
The Molina Healthcare Drug Formulary is a listing of preferred drug products eligible for reimbursement by Molina Healthcare. All medications are listed by generic name. The medications are organized by therapeutic classes. Prescriptions for medications requiring prior approval or for medications not included on the Molina Healthcare Drug Formulary may be approved when medically necessary and when Formulary alternatives have demonstrated ineffectiveness. When these exceptional needs arise, the physician may fax a completed to Molina Healthcare at (844) 823-5479. The forms are also available on the Frequently Used Forms page.
Adobe Acrobat Reader is required to view the file(s) above. Download a free version.