AlohaCare - 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.

MEMBER INFORMATION

First Name: *

Last Name: *

Date of Birth: *

Member ID: *

Spoken Language:

Phone #: *

Email: *

Is this is new phone number? *

YES

ADDRESS

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Is this a new address? *

YES

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

YES

REQUESTOR INFORMATION

Relationship to Member: *

Other (please specify):

Requestor First Name:

Requestor Last Name:

Received Permission from Member/Authorized Representative?

YES

Requestor Spoken Language:

Requestor Phone #:

Requestor Email:

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

YES

ADDITIONAL INFORMATION

Doctor Name: *

Doctor Phone #: *

Pharmacy Name:

Pharmacy Phone #:

Do you have a prescription from your doctor? *

YES

OTHER HEALTH INSURANCE COVERAGE

Do you have other health insurance coverage? *

YES

If yes, name of Other Health Insurance:

Insurance Phone #:

Cardholder Name:

Insurance ID:

Insurance Copay:

SUMMARY OF REQUEST

5000 character limit

Please allow us 24 hours to provide a response to your request.