Member Prescription Drug PA Request Form

For drugs not covered on AlohaCare’s Formulary
  • Use this form to ask us for approval, fill out the form below or call our Customer Service department at 808-973-0712
  • Your doctor must give you a prescription before you can fill out this form. It cannot be completed if you do not have a prescription from your doctor.
* indicates a Required field
MEMBER INFORMATION

Is this is new phone number? *

ADDRESS

Is this a new address? *

Do we have your consent to forward new phone number and/or address to MedQUEST? *

REQUESTOR INFORMATION

Received Permission from Member/Authorized Representative?

Do you give us permission to leave a detailed message about this request?

ADDITIONAL INFORMATION

Do you have a prescription from your doctor? *

OTHER HEALTH INSURANCE COVERAGE

Do you have other health insurance coverage? *

DRUG INFORMATION

Is this a new medicine for you? *

Do you have enough medicine to last until the next business day? *

Is this a new medicine for you? *

Do you have enough medicine to last until the next business day? *

Is this a new medicine for you? *

Do you have enough medicine to last until the next business day? *

Is this a new medicine for you? *

Do you have enough medicine to last until the next business day? *

Is this a new medicine for you? *

Do you have enough medicine to last until the next business day? *

SUMMARY OF REQUEST
5000 character limit
Please allow us 24 hours to provide a response to your request.