Molina Healthcare Of Illinois Pharmacy Prior Authorization Request Form

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Molina Healthcare of Illinois
Pharmacy Prior Authorization Request Form
For Pharmacy PA Requests, Fax: (855) 365-8112
Patient Name
DOB
Date
Patient ID #
Sex
Medication Allergies
Pharmacy
Pharmacy Phone
Pharmacy Fax
*This Form is NOT for buy and bill*
Provider Information
Prescriber Name
NPI #
DEA #
Prescriber Address
Prescriber Specialty
Office Fax
Phone
Office Contact Name
Molina Healthcare is a mandatory generic plan.
Medication Requested
Drug Name
Strength
Dose
Directions (Sig):
ICD-10 & Diagnosis Name
Qty
Refills
Is the Patient currently treated on this medication? ☐ Yes; How long?
N o ☐
Patient Previous Medication(s) Relevant to this Request
Drug Name
Strength
Dose
Directions
Duration Outcome & Reason for Discontinuation
1
2
3
4
Medical Rationale for Request/Additional Clinical Information (Including diagnostic studies, lab results, & progress notes)
Provider Signature
Date
35129IL0913

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