Get Texas Standardized Prior Authorization Bformb - Molina Healthcare

Filling out the Texas Standardized Prior Authorization BFormb for Molina Healthcare can be a streamlined process when approached with clarity. This guide will assist you in navigating each section of the form online, ensuring that you provide complete and accurate information to facilitate timely processing.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the form and open it in the editing interface.
2. In Section I — Submission, enter the name of the department you are submitting to, which is Molina Pharmacy Prior Authorization Department. Additionally, include your phone number, fax number, and the date of submission.
3. Section II — Review includes an option for expedited or urgent review. If applicable, check the box and ensure you sign below to certify the necessity for expedited review.
4. In Section III — Patient Information, fill in the patient's name, phone number, address, date of birth, gender, and any relevant identification numbers such as Member ID, Group #, BIN #, and PCN #. Make sure all details are accurate.
5. Complete Section IV — Prescriber Information with the prescriber's name, NPI number, contact details, and specialty. This section ensures the prescriber's credentials are correctly noted.
6. In Section V — Prescription Drug Information, specify the requested drug name, strength, route of administration, quantity, expected therapy duration, and whether the medication is a new therapy or a continuation. Include HCPCS Code and NDC# if applicable.
7. If requesting a compound drug, fill out Section VI — Prescription Compound Drug Information with the compound drug name, each ingredient's NDC and quantity.
8. Section VII — Prescription Device Information requires you to list the requested device name and the expected duration of use.
9. In Section VIII — Patient Clinical Information, provide the patient's diagnosis, drugs they have previously taken, and any relevant laboratory values. Document any allergies and relevant clinical history to support the request.
10. Finally, complete Section IX — Justification as instructed in the guidelines. Review all sections to ensure completeness and accuracy.
11. After filling out all sections, save changes, download, print, or share the form as necessary to submit your prior authorization request.

Complete your Texas Standardized Prior Authorization BFormb online to ensure efficient processing of your request.