Forms
Here you can find all your provider forms in one place. If you have questions or suggestions, please contact Provider Services at (844) 236-1464.
- Authorizations/Utilization Management
To submit a prior authorization request:
1. Log in to Availity
2. Select Patient Registration from the top navigation
3. Then, select Auth/Referral Inquiry or Authorizations
At this time, you are not required to submit all prior authorization requests using Availity, but we do encourage you to use this method for quicker authorization turnaround times. Molina Iowa UM Fax: (877) 319-6828.
Universal Prior Authorization:Medicaid Supplemental Information PA Form
Inpatient Medicaid Prior Authorization Form
Iowa Medicaid Resources
Please download these guides for Molina fax information:
Inpatient Medicaid PA Resource Guide
Outpatient Medicaid PA Resource Guide
Prior Authorization Code ListsPrior Authorization Reconsiderations and Appeals
- Claims Forms
* Once complete, please fax form to Molina Healthcare of Iowa Appeals and Grievances at 1-855-275-3082.
- Overpayment Forms
- Provider Network Forms
- Pharmacy Forms
- Aripiprazole Tablets with Sensor (Abilfy MyCite) PA Form
- Adenosine Triphosphate Citrate Lyase Inhibitors PA Form
- Acute Migraine Treatments PA Form
- Tralokinumab-ldrm (Adbry) PA Form
- Age Edit Override Codeine Tramadol PA Form
- Alpha1 Proteinase Inhibitor Enzymes PA Form
- Dalfampridine (Ampyra) PA Form
- Amylino Mimetic PA Form
- Antidepressants PA Form
- AntiDiabetic NonInsulin Agents PA Form
- Antiemetic-5HT3 Receptor Antagonists-Substance P Neurokinin Agents PA Form
- Anti-Fungal PA Form
- Antihistamines PA Form
- Apremilast (Otezla) PA Form
- Baclofen PA Form
- Binge Eating Disorder Agents PA Form
- Benzodiazepines PA Form
- Biologicals Arthritis PA Form
- Biologicals Axial Spondyloarthritis PA Form
- Biologicals For Hidradenitis Suppurativa PA Form
- Biologicals For Inflammatory Bowel Disease PA Form
- Biologicals Plaque Psoriasis PA Form
- Mannitol Inhalation Powder (Bronchitol) PA Form
- Odevixibat (Bylvay) PA Form
- Mavacamten (Camzyos) PA Form
- Cholic Acid (Cholbam) PA Form
- CNS Stimulants and Atomoxetine PA Form
- Ivabradine (Corlanor) PA Form
- Cystic Fibrosis Agents Oral PA Form
- Deferasirox (Exjade) PA Form
- Direct Oral Anticoagulants PA Form
- Triheptanoin (Dojolvi) PA Form
- Dupilumab (Dupixent) PA Form
- Duplicate Therapy Override PA Form
- Pegcetacoplan (Empaveli) PA Form
- Satralizumab (Enspryng) PA Form
- Erythropoesis Stimulating Agents PA Form
- Crisaborole (Eucrisa) PA Form
- Risdiplam (Evrysdi) PA Form
- Extended Release Formulation PA Form
- Fentanyl Short-Acting Products PA Form
- Fifteen Day Initial Prescription Supply Override PA Form
- GLP-1 Agonist Basal Insulin Combination PA Form
- Gonadotropin Releasing Hormone (GnRH) Receptor Antagonist Oral PA Form
- Granulocyte Colony Stimulating Factor PA Form
- Growth Hormone PA Form
- Hematopoietic Chronic ITP PA Form
- Hepatitis C Treatments Direct Acting Antivirals PA Form
- High Dose Opioids PA Form
- IL5 Antagonists PA FormI
- Incretin Mimetics for Non-Diabetes Indications PA Form
- Initial Days Supply Limit Override PA Form
- Isotretinoin Oral PA Form
- Janus Kinase Inhibitors PA Form
- Finerenone (Kerendia) PA Form
- Ketorolac PA Form
- Sapropterin (Kuvan) PA Form
- Lidocaine Patch PA Form
- Maralixibat (Livmarli) PA Form
- Long Acting Opioids PA Form
- Methotrexate Injection PA Form
- Korlym (mifepristone) PA Form
- Miscellaneous PA Form
- Modified Formulations PA Form
- Muscle Relaxants PA Form
- Naloxone Nasal Spray PA Form
- Narcotic Agonist Antagonist Nasal Spray PA Form
- New Market Drugs PA Form
- Nocturnal Polyuria Treatments PA Form
- Select Non-Biologic Agents for Ulcerative Colitis PA Form
- Non-Parenteral Vasopressin Derivatives PA Form
- Non-Preferred Drug PA Form
- Nonsteroidal Anti-Inflammatory Drugs PA Form
- Dextromethorphan and Quinidine (Nuedexta) PA Form
- Ensifentrine (Ohtuvayre) PA Form
- Ophthalmic Agents for Presbyopia PA Form
- Oral Constipation Agents PA Form
- Oral Glucocorticoids for Duchenne Muscular Dystrophy PA Form
- Oral Immunotherapy PA Form
- Multiple Sclerosis Agents Oral PA Form
- Ospemifene (Osphena) PA Form
- Peanut (Arachis Hypogaea) Allergen Powder-dnfp (Palforzia) PA Form
- Pavilizumab PA Form
- PCSK9 Inhibitors PA Form
- Pirfenidone (Esbriet) and Nintedanib (Ofev) PA Form
- Letermovir (Prevymis) PA Form
- Proton Pump Inhibitors PA Form
- Pulmonary Arterial Hypertension Agents PA Form
- Viloxazine (Qelbree) PA Form
- Quantity Limit Override PA Form
- Calcifediol (Rayaldee) PA Form
- Repository Corticotropin Injection PA Form
- Roflumilast (Daliresp) PA Form
- Sedative Hypnotic Non-Benzodiazpine PA Form
- Select Anticonvulsants PA Form
- Selected Brand Name Drug PA Form
- Select Oncology Agents PA Form
- Select Preventative Migraine Treatments PA Form
- Select Topical Agents PA Form
- Short-Acting Opioids PA Form
- Sodium Oxybate Products PA Form
- Deucravacitinib (Sotyktu) PA Form
- Tasimelteon (Hetlioz) PA Form
- Testosterone Products PA Form
- Tezepelumab-ekko (Tezspire) Prefilled Pen PA Form
- Topical Acne and Rosacea Products PA Form
- Topical Antifungals for Onychomycosis PA Form
- Topical Corticosteroids PA Form
- Immunomodulators Topical PA Form
- Cyclosporine Ophthalmic 0.1% Emulsion (Verkazia) PA Form
- Vericiguat (Verquvo) PA Form
- Eluxadoline (Viberzi) PA Form
- Alpelisib (Vijoice) PA Form
- Vitamins Minerals and Multiple Vitamins PA Form
- Vesicular Monoamine Transporter (VMAT) 2 Inhibitors PA Form
- Vonoprazan (Voquezna) PA Form
- Miconazole Zinc Oxide White Petrolatum (Vusion) Ointment PA Form
- Omalizumab (Xolair) PA Form
- Rifaximin (Xifaxan) PA Form
- Zuranolone (Zurzuvae) PA Form
- Linezolid (Zyvox) PA Form
- Women’s Health Services
- Pregnancy Notification Form
- Newborn Notification Form (to be completed, and faxed/emailed to Molina within 12 hours of birth)