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MEDICATION PRIOR AUTHORIZATION REQUEST FORM for members under Hawaii Western Management Group, Inc. (HIM)Fax completed form to 888.610.1180 or email to PASupport@RxBenefits.com Electronic version

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How to fill out medication prior authorization request

1. Obtain the medication prior authorization form from your healthcare provider or insurance company.
2. Fill out the patient information section, which includes your name, date of birth, and contact information.
3. Provide details about your healthcare provider, including their name, address, and phone number.
4. List the medication for which you need prior authorization, including the name, dosage, and frequency.
5. Include the reason for the medication request, whether it is a new prescription, a change in medication, or a medication not covered by your insurance.
6. Attach any supporting documentation that may be required, such as medical records or letters of medical necessity.
7. Review the form for accuracy and completeness.
8. Submit the completed medication prior authorization request to your healthcare provider or insurance company as instructed.
9. Keep a copy of the authorization request form and any supporting documents for your records.
10. Follow up with your healthcare provider or insurance company to ensure that your prior authorization request is processed in a timely manner.

Who needs medication prior authorization request?

1. Anyone who requires a specific medication that requires prior authorization from their insurance company needs to fill out a medication prior authorization request.
2. This includes individuals whose prescriptions are not covered by their insurance, individuals who need a new prescription, individuals who need a change in medication, or individuals whose medication requires periodic reauthorization.
3. It is important to check with your insurance company or healthcare provider to determine if a medication prior authorization request is required for your specific situation.

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What is medication prior authorization request?

A medication prior authorization request is a formal process through which healthcare providers must obtain approval from a health insurance company before a specific medication is prescribed to ensure coverage.

Who is required to file medication prior authorization request?

Typically, the healthcare provider prescribing the medication is required to file the medication prior authorization request on behalf of the patient.

How to fill out medication prior authorization request?

To fill out a medication prior authorization request, a provider must complete a form provided by the insurance company that includes patient information, medication details, clinical justification, and supporting documents.

What is the purpose of medication prior authorization request?

The purpose of a medication prior authorization request is to ensure that prescribed medications are medically necessary, appropriate, and cost-effective, and to manage healthcare costs for insurance companies.

What information must be reported on medication prior authorization request?

Information that must be reported includes patient demographics, the prescribed medication, diagnosis, treatment history, and any supporting clinical information that justifies the need for the medication.