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Hawaii Medicaid Prior (Rx) Authorization Form

Hawaii Medicaid Prior (Rx) Authorization Form

Updated July 27, 2023

Hawaii Medicaid prior authorization form requests State coverage of a non-preferred medication for a patient in the State of Hawaii. The person making this request will need to justify why they are not prescribing medication from the Preferred Drug List (PDL). They should also attach any relevant medical documentation and office notes that help justify their request. The form and attachments should then be sent by fax or mail to the correct directory for review.

Preferred Drug List – list of State pre-approved prescriptions