Professional Fax Cover Sheet - DOC 10

							                                                 Phone 888 – 483-0760                    MOLINA ADVANTAGE
                                                 FAX 866 – 771-0117
                                                                                           Medication Prior
                                                                                            Authorization
                                                                                         Request Form of Utah
                                                                                               Part D
To insure a quick response time, please fill out form completely.
This will not be considered a completed request until all
information needed to render a decision has been provided.
Date:                                                      Time:

Pt. Name:                                                  DOB:

Pt. I.D. #

MD’s Name/Specialty:

Phone #:                                                   Fax #:



 Drug: (Name, strength, dose and directions)

 New Drug

 Renewal




 Diagnosis/Medical Indications for RX: (Send all pertinent test results with this fax)




 Previous Therapy/ RXs tried: (Length of treatment/outcome)




For MOLINA          ________ ___________________                    ________                                  ________
Use Only            Approved Length of Auth                         Pend                                      Denied
Comments:




Denial codes:
Date                                                                              Reviewer      Initials:
Denial Codes: 1) Non-formulary 2) Off label use 3) Not medically Necessary                    4) Inappropriate Rx

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