Request Medicaid Prescription Drug Coverage

Who May Make a Request

Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact Us to learn how to name a representative.

A Medicaid Drug Coverage Request Form (PDF) may be faxed to the ‘Ohana Pharmacy Department at 1-866-825-2884.

If you need help filling out this form, you may ask your doctor or call us at 1-888-846-4262 (TTY 711). We’re here for you Monday through Friday, 7:45 a.m. to 4:30 p.m. HST.

Enrollee’s Information

First Name

Last Name

ID Number

Date of Birth

Enrollee’s Contact Information

Email Address

Phone Number

Street Address

Zip Code

City

State

Requestor’s Contact Information

Complete the following section ONLY if the person making this request is not the enrollee:

First Name

Last Name

Relationship to Enrollee

Phone Number

Street Address

Zip Code

City

State

Attach documentation showing the authority to represent the enrollee and enter a brief explanation below. For more information on appointing a representative, contact your plan.

Prescription Drug Requested

Name of prescription drug you are requesting (if known, include strength and quantity requested per month)

Prescriber’s Information

First Name

Last Name

Phone Number

Fax Number

Street Address

Zip Code

City

State

Prescriber's Signature

Date

Diagnosis and Medical Information

Medication/Strength and Route of Administration

Frequency

Start Date

Expected Length of Therapy

Quantity

Weight

Height

Diagnosis

Drug Allergies

Rationale for Request

Select all that apply.

Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy, or therapeutic failure

Drug(s) contraindicated or tried

Adverse outcome for each

If therapeutic failure, length of therapy on each drug(s)

Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change

Anticipated significant adverse clinical outcome

Medical need for different dosage form and/or higher dosage

Dosage form (s) and/or dosage(s) tried

Medical Reason

Other (provide details)

* Explanation

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Y0020_WCM_164006E_M Last Updated On: 10/1/2024

Request Medicaid Prescription Drug Coverage

Who May Make a Request

Please correct the following errors:

Please correct the following errors

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Requested

Prescriber’s Information

Diagnosis and Medical Information

Rationale for Request

Need help? We're here for you.

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Request Medicaid Prescription Drug Coverage

Who May Make a Request

Please correct the following errors:

Please correct the following errors

Enrollee’s Information

Enrollee’s Contact Information

Requestor’s Contact Information

Prescription Drug Requested

Prescriber’s Information

Diagnosis and Medical Information

Rationale for Request

Need help? We're here for you.