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If you have any questions, please contact Member Services.

 Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina Dual Options at:

Molina Healthcare of California
200 Oceangate, Suite 100
Long Beach, CA 90802

 How to Request Coverage Determination – To request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, or reimbursement for a coverage drug that you purchased at an out-of-network pharmacy.

Mail or fax the form to:

Molina Healthcare of Utah
7050 Union Park Center, Suite 600
Midvale, UT 84047

Fax: (866) 290-1309

You can also complete an online secure form by clicking here.

 How to Request a Redetermination – Please read this document to understand what you need to do to request an appeal.

 Request a Redetermination – You can also download this form and mail or fax it to:

Fax: (866) 771-0117

You can also complete an online secure form by clicking here.

 Direct Member Reimbursement Form – Use this form to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.

Medicare.gov Complaint Form – Click here for the Medicare Complaint Form. You may also access additional information on Medicare's website at www.medicare.gov

*Printed copies of information posted on our website are available upon request.

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