Medical Policies

Medical Policies provide members with detailed information about how HMSA evaluates and determines coverage for various health services and procedures. These policies are developed using evidence-based guidelines and clinical best practices to ensure that care is medically necessary and appropriate. Members can use these policies to understand what services are covered under their plan, any limitations or exclusions, and the criteria used to approve treatments. Whether  a member is preparing for a procedure or reviewing their benefits, these policies help clarify what to expect and how decisions are made.

Access – Located in the HMSA Provider Resource Center under Medical Policies

Specialty Drugs

A specialty drug is a drug that is typically high in cost and has one or more of the following characteristics:

• Specialized patient training on how to take the drug is required. This includes supplies and devices needed for administration.
• Coordination of care is required before starting drug therapy and/or during therapy.
• Unique patient compliance and safety monitoring requirements.
• Unique requirements for handling, shipping, and storage.
• Restricted access or limited distribution.

Pharmacy Specialty Drug Policies

• Access – Located in the HMSA Provider Resource Center under Pharmacy Specialty Drug Policies. 
• The pharmacy specialty drug policies focus on oral, inhaled, and topical drugs, which are self-administered.
• These policies determine which drugs need precertification and include utilization management criteria requirements for approval. Policies are reviewed annually for new clinical evidence or regulatory changes.
• Members can refer to these policies to understand how HMSA manages access to specialty drugs indicated for conditions such as cancer, autoimmune diseases, and rare conditions.

Medical Specialty Drug Policies

• Access – Located on the HMSA Provider Resource Center under Medical Specialty Drug Policies.
• The medical specialty drug policies focus on injectable and infusible drugs, which can be self-administered or administered in clinical settings (e.g., physician office or outpatient infusion suite).
• These policies determine which drugs require precertification and include utilization management criteria requirements for approval. Policies are reviewed annually for new clinical evidence or regulatory changes.
• Members can refer to these policies to understand how HMSA manages access to specialty drugs indicated for conditions such as cancer, autoimmune diseases, and rare conditions.