Hawaii Medicaid Prior (Rx) Authorization Form

Updated January 23, 2022

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

How to Write

Step 1 – Begin by entering the date in the “Request Date” field. Then, enter the full name, phone number, gender, date of birth, and member ID number of the patient into the “Patient Information” section.

Step 2 – In the “Provider Information” section, you will need to enter the provider’s name, contact person, phone number, fax number, provider address, pharmacy address, pharmacy name, whether this is a routine or urgent request, and the pharmacy phone and fax number.

Step 3 – In the “Physician Section” section, you are asked to enter provide the relevant diagnosis and code, the period requested, and prognosis. Next, enter the medication name, whether this is a new or continuing prescription, strength, and dosage, quantity, number of refills, and the directions for use. Below that, describe other medications used in the treatment of this diagnosis, the reason for the failure of treatment, and write your other justifications for making this request, attaching relevant medical documents and notes. You also must provide the written signature of the prescriber and the date.

Step 4 – Finally, in the “Insurance Plans that Have Agreed to Accept This Form” section, you must check the applicable insurance company (or companies) which will accept this form.