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 Confidentiality Notice: This fax transmission, including any attachments, contains confidential information that may be privileged. The information is intended only for the use of the individual(s) or entity to which it is addressed. If you are not the intended recipient, any disclosure, distribution or the taking of any action in reliance upon the fax transmission is prohibited and may be unlawful. If you have received this fax in error, please notify the sender immediately via telephone at the above phone number and destroy the original documents. Thank you.
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