Get Molina Redetermination Online Form

This guide provides clear, step-by-step instructions on how to efficiently complete the Molina Redetermination Online Form. Whether you are appealing a Medicare prescription drug denial or seeking assistance on behalf of another individual, the following steps will help ensure that your request is submitted correctly.

Follow the steps to successfully complete your appeal request.

1. Press the ‘Get Form’ button to obtain the Molina Redetermination Online Form and open it in your preferred editor.
2. Fill in the enrollee's information, including their full name, date of birth, address, city, state, zip code, and phone number.
3. Enter the enrollee’s plan ID number to link the submission to the specific Medicare plan.
4. If the request is being made by someone other than the enrollee, complete the requestor's information. This includes their name, relationship to the enrollee, address, city, state, zip code, and phone number.
5. Attach any required representation documentation, such as a completed Authorization of Representation Form or a written equivalent, if the requestor is not the enrollee or prescriber.
6. Indicate the prescription drug being requested by providing the name, strength/quantity/dose, and if applicable, details of any purchase pending the appeal.
7. If the drug was already purchased, fill in the purchase date, amount paid, and the name and phone number of the pharmacy.
8. Complete the prescriber's information, including their name, address, city, state, zip code, office phone, fax number, and office contact person.
9. If an expedited decision is necessary, select the appropriate checkbox and attach any supporting statements from the prescriber.
10. Provide a detailed explanation of your reasons for appealing. You may attach additional pages if needed and include any relevant information that supports your case.
11. Finally, ensure that the appeal request is signed by the person making the appeal (enrollee, prescriber, or representative) and include the date of the signature.

Complete your Molina Redetermination Online Form now to ensure your appeal is processed in a timely manner.