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, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy.
Molina Healthcare of Utah
7050 Union Park Center, Suite 200
Midvale, UT 84047
Fax: (866) 290-1309
How to Request a Redetermination - Please read this document (PDF) to understand what you need to do to request an appeal.
Attn: Grievance and Appeals
P.O. Box 22816
Long Beach, CA 90801-9977
Fax: (866) 771-0117
Pharmacy Direct Member Reimbursement Form - Use this form (PDF) to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.
*Materials are also available in printed and alternative formats, such as large print, audio, or Braille.
Adobe Acrobat Reader is required to view the file(s) above. Download a free version.
Medicare.gov Complaint Form