PRIOR AUTHORIZATION/MEDICATION …

PRIOR AUTHORIZATION/MEDICATION exception REQUESTM olina healthcare of WashingtonPhone: (800) 213-5525 Option 1-2-2 | Fax: (800) 869-77918243078WA0917 Urgent ReauthorizationPatient InformationFirst Name:MI:Last Name:DOB:Member ID:Physician InformationFirst Name:MI:Last Name:Prescriber Phone:Prescriber Fax:Physician NPI:Specialty: medication Information (This information is required for processing)*Generic substitution is required when availableDrug Name, Strength and Directions:Pharmacy Name:Pharmacy NPI:Pharmacy Phone:Pharmacy Fax:Diagnosis/Medical Justification:Previous Medications Tried and Dates of Use:Comments:Physician Signature (I certify that all of the information on this form is true and accurate to the best of my knowledge)XDate:Approvals are subject to the member s co-pays and deductibles for their plan and all authorized prescriptions must be fi

PRIOR AUTHORIZATION/MEDICATION EXCEPTION REQUEST Molina Healthcare of Washington Phone: (800) 213-5525 Option 1-2-2 | Fax: (800) 869-7791 8243078WA0917

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