Professional Fax Cover Sheet - DOC 10 by VBKuIn


									                                                 Phone 888 – 483-0760                    MOLINA ADVANTAGE
                                                 FAX 866 – 771-0117
                                                                                           Medication Prior
                                                                                         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

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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