Essential Formulary Coverage Determination Request

Download

A coverage determination is HMSA’s initial decision about whether we’ll cover a prescription drug through your Essential Prescription Formulary.

Your doctor can ask us to make a coverage determination about the drug(s) you need. If your health requires a quick response, your doctor can make an "expedited coverage determination." After we receive your doctor’s statement, we’ll give you an answer within:

  • 72 hours for a standard coverage determination.
  • 24 hours for an expedited coverage determination.

Instructions

  1. Click Download at the top of the page.
  2. Print out the form and take it to your doctor to complete.
  3. Ask your doctor to submit the completed form by phone, fax, or mail.

Phone: 1-855-240-0543

Fax: 1-855-762-5207

Mail:
HMSA
P.O. Box 30980
Honolulu HI 96820-9930
Attn: PA department

If you have questions about the request process or the status of a request, contact CVS/caremark, HMSA’s pharmacy benefits manager. Call 1-855-240-0543 toll-free, 24 hours a day, seven days a week. TTY users, please call 1-800-863-5488 toll-free.

CVS/caremark provides pharmacy benefit management services and manages HMSA’s drug formulary for HMSA’s commercial, Medicare, and QUEST Integration plans. CVS/caremark is an independent company.