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Hawaii Community Plan Pharmacy Prior Authorization Forms

To simplify your experience with prior authorization and save time, please submit your prior authorization request through the following online portals:

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Electronic Prior Authorization (ePA)

Submit an ePA using CoverMyMeds

Select Electronic Prior Authorization (ePA)
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Electronic prior authorization (ePA)

Submit an ePA using SureScripts

Select Electronic prior authorization (ePA)

Otherwise, you can submit requests by completing and faxing the applicable form below. You can search for a drug specific form by entering the requested drug in the search box below. If your search does not yield a result, please use this Prior Authorization Request form.

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  • ADHD Products (HI, NJ, NY-CHIP, PA-CHIP, RI) Prior Authorization Form - Community Plan

    Last Published 04.01.2023

    "Brand Adderall, generic amphetamine/dextroamphetamine, Brand Adderall XR, generic amphetamine/dextroamphetamine ER, Brand Intuniv, generic guanfacine ER, Brand Metadate ER, generic methylphenidate ER tab, generic methylphenidate ER (CD), Brand Concerta, generic methylphenidate ER OSM, Brand Ritalin, generic methylphenidate, generic methylphenidate ER (LA), Brand Ritalin LA, Brand Strattera, generic atomoxetine, Brand Vyvanse, Adhansia XR, Brand Adzenys XR-ODT, Brand Adzenys ER, generic amphetamine ER susp, Brand Aptensio XR, generic methylphenidate ER cap, Brand Cotempla XR-ODT, Brand Daytrana, Brand Desoxyn, generic methamphetamine, Brand Dexedrine, generic dextroamphetamine ER, Brand Dyanavel XR, Brand Evekeo, Evekeo ODT, generic amphetamine, Brand Focalin, generic dexmethylphenidate, Brand Focalin XR, generic dexmethylphenidate ER, Jornay PM, Brand Kapvay, generic clonidine ER, Brand Methylin, generic methylphenidate soln, Brand Mydayis, Brand Procentra, generic dextroamphetamine soln, Brand Quillichew ER, Brand Quillivant XR, Brand Zenzedi, generic dextroamphetamine, generic Relexxii, generic methylphenidate ER (OSM), Qelbree, Azstarys, generic methylphenidate patch ",
  • Cough and Cold Products (Hawaii) Prior Authorization Form - Community Plan

    Last Published 02.22.2022

    Hydromet, hydrocodone-homatropine, Z-Tuss AC, Tuzistra XR, Tussicaps, hydrocodone-chlorpheniramine, M-END PE, Poly-Tussin AC, Capcof, Pro-Red AC, Histex-AC, Maxi-Tuss, promethazine w/codeine, Promethazine VC/codeine, promethazine-phenylephrine-codeine, Rydex, Mar-Cof BP/Mar-Cof GG, Ninjacof-XG, Coditussin AC/Coditussin DAC, guaifenesin-codeine, Lortuss EX, pseudoephedrine w/codeine-guaifenesin, Tuxarin ER,
  • Dupixent (AZ, HI, MD, NJ, NY-CHIP, NY-EPP, PA-CHIP, RI) Prior Authorization Form - Community Plan

    Last Published 04.01.2023

    Dupixent,
  • GLP-1 Agonists (HI, MD, NJ, NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan

    Last Published 04.01.2023

    Adlyxin, Bydureon, Byetta, Ozempic, Rybelsus, Trulicity, Victoza,
  • Hepatitis C Medications (Hawaii) Prior Authorization Form - Community Plan

    Last Published 02.22.2022

    Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier,
  • Medicaid Synagis Authorization Request Form - Community Plan

    Last Published 04.01.2023

    Synagis,
  • Opioid Products (Hawaii) Prior Authorization Form - Community Plan

    Last Published 02.22.2022

    Morphine ER, Xtampza, tramadol ER, Hydromorphone ER, MS Contin, fentanyl transdermal, Zohydro ER, hydrocodone ER, Oxymorphone ER, Methadose, Methadone, Hysingla ER, Oxycontin, oxycodone CR, Nucynta ER, Duragesic, Conzip Butorphanol, carisoprodol-aspirin-codeine, codeine, acetaminophen-codeine, butalbital-acetaminophen-caffeine-codeine, Fioricet-codeine, butalbital-aspirin-caffeine-codeine, morphine, hydrocodone-acetaminophen, Lortab, Xodol, hydrocodone-ibuprofen, Dilaudid, hydromorphone, oxycodone, Roxicodone, Oxaydo, oxycodone-acetaminophen, Percocet, Prolate, Nalocet, Endocet, oxycodone-aspirin, oxymorphone, pentazocine-naloxone, Ultram, Synapryn, tramadol, Ultracet, tramadol-acetaminophen, Qdolo, Nucynta, meperidine, levorphanol, acetaminophen-caffeine-dihydrocodeine, Trezix, belladonna alkaloids-opium, opium, Apadaz, benzhydrocodone-acetaminophen ,
  • SGLT-2 Inhibitors (HI, MD, NJ, NY-CHIP, PA-CHIP) Prior Authorization Form - Community Plan

    Last Published 04.01.2023

    Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, Synjardy XR, Farxiga, Xigduo XR,
  • Suboxone/Subutex (Hawaii) Prior Authorization Form - Community Plan

    Last Published 02.22.2022

    buprenorphine/naloxone sublingual tablet, buprenorphine sublingual tablet, Suboxone Film, buprenorphine/naloxone film, Zubsolv, Bunavail,