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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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  • 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,
  • Hepatitis C Medications (Hawaii) Prior Authorization Form - Community Plan

    Last Published 02.22.2022

    Epclusa, sofosbuvir/velpatasvir, Harvoni, ledipasvir/sofosbuvir, Mavyret, Sovaldi, Vosevi, Zepatier,
  • 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 ,
  • 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,