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Molina Healthcare Prior (Rx) Authorization Form

Molina Healthcare prior authorization form is submitted by a physician to request coverage for a patient's prescription. It should be noted that the medical office will need to provide justification for requesting the specific medication, and that authorization is not guaranteed. We have provided all of the necessary forms and contacts below.
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Fax to:

  • California: 1(866) 508-6445
  • Florida: 1(866) 236-8531
  • Illinois: 1(855) 365-8112
  • Michigan & Wisconsin: 1(888) 373-3059
  • New Mexico (Medicaid): 1(877) 262-0187
  • New Mexico (Medicare): 1(855) 278-0310
  • Ohio: 1(800) 961-5160
  • South Carolina: 1(855) 571-3011
  • Texas (Medicaid): 1(866) 420-3639 / Pharmacy: 1 (888) 487-9251
  • Texas (Medicare): 1(844) 251-1450 / Pharmacy: 1 (866) 290-1309
  • Utah: 1(866) 497-7448
  • Washington: 1(800) 869-7791

Phone:

  • California: 1(888) 665-4621
  • Florida: 1(866) 472-4585
  • Michigan: 1(855) 322-4077
  • Wisconsin: 1(855) 326-5059
  • Ohio: 1(800) 642-4168
  • Utah: 1(888) 483-0760
  • Washington: 1(800) 213-5525

By State