Decorative arrowsHMSA Provider Resource Center
HomeNews and AlertsE-LibraryMedicare E-LibraryCommunications ArchiveQUEST Integration
Frequently Asked QuestionsUseful Web SitesContacting HMSA
HMSA Logo
 
Benefits and Copayments
Why Does HMSA Have A Formulary?
Formularies
CVS Caremark Prior Authorization
Mail Order
Information for Pharmacies
Information for Providers
Formulary Search

Pharmacy and Formulary

Benefits and Copayments

 

 

 

 

Back to Top

Why Does HMSA Have A Formulary?

HMSA embraces the concept that appropriate drug therapy is an integral part in managing patients in the outpatient setting and results in the best outcomes for our members and helps to manage the overall cost of care. However, health care costs continue to rise due to:

  • Increased utilization by an aging population and more aggressive diagnosis and treatment regimens
  • High costs associated with new technology
  • Use of high cost brand drugs which are selected based on drug manufacturer marketing techniques of direct-to-consumer advertising and physician detailing
  • A reduction in savings traditionally associated with generic drugs as demonstrated by pricing trends, generic patent strategies, and periods of 'exclusivity' for some of the newer generics drugs.

The State of Hawaii's Prepaid Health Care Act requires employers to offer medical insurance to full-time employees. However, prescription drug benefits are not included in this mandate. Thus, as health care costs continue to rise, employer groups may seek to reduce associated expenses by opting for plans which offer limited drug benefits or, in the worst case, not offer drug coverage at all.

 

The cost of medications for members with limited or no drug coverage often hinders access to care and restricts treatment options for physicians. Thus, HMSA is committed to working closely with physicians, members, and employers to maintain a high-quality, affordable pharmacy benefit program and to help ensure that members have access to the medications they need. We believe that the appropriate use of cost-effective medications, as supported by practice guidelines, quality programs and formulary decisions is our best defense against benefit reductions.

 

Our approach to pharmacy management is one which incorporates benefit designs which are clinically supported by our formulary and directly tied to managed care programs which promote appropriate use of drugs.

 

 

What Is The Formulary?

The HMSA Drug Formulary is a detailed listing of medications that outlines member benefit levels (copayment levels and/or absolute coverage) for HMSA drug plans. Refer to HMSA Drug Plans for descriptions of current HMSA drug plans. The formulary:

  • is a reference to assist physicians in drug therapy selection for HMSA members.
  • is not intended to replace the professional judgment exercised by providers overseeing patient care.
  • Applies only to outpatient prescription medications dispensed by participating providers. It does not apply to inpatient medications or medications obtained from and/or administered by a physician.
  • is designed to be as comprehensive as possible, but does not list all drugs currently available in the United States
  • is subject to change. Providers who utilize HMSA's point-of-sale (POS) pharmacy claims processor have access to the most accurate and up-to-date formulary information.

New drugs, strengths, forms and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following completion of HMSA’s review process

 

 

Back to Top

Formularies

 

HMSA Formulary †,* HMSA Medicare HMSA QUEST Integration **
HMSA's Select, Choice and Childrens Drug Formulary HMSA's Medicare Plans Formularies HMSA's QUEST Integration Drug Formulary
HMSA's Control Formulary    
HMSA's Essential Prescription Formulary    
HMSA's Metallic Prescription Formulary    

 

Hawaii Healthcare Information Network (HHIN) Login

 

Brand drugs not listed in the formulary should be considered OTHER BRAND.

* The online HMSA Drug Formulary is updated quarterly. Providers may request a CD version of the formulary by contacting HMSA Provider Services.

**Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type may be generically available. If the generic is boldfaced, the generic is covered and the brand name product will be non-formulary. The exception is for State mandated drug classes (Anti-Retroviral Agents, Hepatitis C Agents, Anti-Depressants, Anti-Psychotics, Anti-Anxiety Agents, and Immunosuppressants), where both the generic is covered as well as the brand name product equivalent with a dispense as written code 1 (DAW).

 

 

 

HMSA Pharmacy & Therapeutics (P&T) Advisory Committee

The HMSA Pharmacy & Therapeutics (P&T) Advisory Committee serves to advise HMSA regarding its health plan coverage to ensure HMSA members have access to high-quality, cost-effective medications. The P&T Advisory Committee meets on a quarterly basis and provides HMSA with recommendations regarding:

  • Drug management programs which serve to enhance the appropriate use of drugs. Such management programs include, but are not limited to, drug utilization review (DUR), member safety initiatives, therapeutic or clinical protocols, therapeutic interchange, diagnoses requirements, age or gender edits, quantity limits, and stepped therapy.

 

The P&T Advisory Committee is comprised of practicing physicians and pharmacists from the community, who serve voluntarily and are not compensated for their participation. HMSA Medical Directors, representing each of HMSA's major lines of business, and staff pharmacists serve as non-voting members of this committee.

 

 

Drug Evaluation Process

  • Review Criteria

For a drug to be reviewed for proposed change due to the HMSA formulary, it must be approved by the Federal Food and Drug Administration (FDA) for an indication(s) that would benefit patients in an outpatient setting with a covered medical condition. The drug must also offer a distinct clinical advantage(s) over existing medications of comparable therapeutic effects listed on the formulary.

  • Review Requests

Providers requesting changes of a drug status on the formulary are asked to explain the reason for their request, to suggest appropriate restrictions or guidelines for use, and to provide references from medical literature to be included in the review.

HMSA-Pharmacy Management

818 Keeaumoku St. IB-Pharmacy

Honolulu, HI 96814

Fax: (808) 593-0591

 

Please email questions or comments regarding HMSA Drug Formulary revisions to HMSAPharmacists@HMSA.com.  Incomplete applications will be returned to the requestor.

 

 

Back to Top

CVS Caremark Prior Authorization

Effective Jan. 1, 2013, CVS Caremark will be handling all the prior authorization requests for HMSA's commercial business, QUEST Integration and Medicare Part D members.

 

To request a prior authorization, physicians may contact CVS Caremark at the appropriate toll-free number listed in the table below. Physicians may also complete a prior authorization fax form and fax it to CVS Caremark. Pharmacists may also initiate a prior authorization, after which CVS Caremark will contact the appropriate physician's office to complete the request.

 

 Request Method Commercial QUEST Integration Medicare
Electronic PAs  http://www2.caremark.com/epa/ http://www2.caremark.com/epa/ http://www2.caremark.com/epa/
Phone 1 (855) 240-0543 1 (855) 220-5732 1 (855) 479-3659
TTY 1 (800) 863-5488 1 (808) 863-5488 711
Fax 1 (855) 762-5207 1 (855) 762-5206 1 (855) 633-7673
Hours of Operation Monday - Friday, 7:45 a.m. - 5:00 p.m., Hawaii Standard Time Monday - Friday, 7:45 a.m. - 5:00 p.m., Hawaii Standard Time Monday - Friday, 8:00 a.m. - 8:00 p.m., Hawaii Standard Time
After-hours Phone 1 (855) 298-2491 1 (855) 479-3656 1 (855) 479-3659

 

 

Exceptions

 

Formulary Exceptions (QUEST Integration, Part D, Essential Prescription, and Control Non-Formulary)
Exceptions are required for drugs that are not on the formulary. Please click on the links in the columns to the right for instructions and documentation required to support a request for a formulary exception.

QUEST Integration Formulary Exceptions

 

Med D Formulary Exceptions

 

Essential Prescription Non-Formulary Exceptions

 

Control Formulary Non-Formulary Exceptions

 

Tiering Exceptions (Commercial and Part D)

Exceptions may be reviewed to allow consideration for:

  • Commercial: higher cost OTHER BRAND drugs to be covered at Preferred Brand copays. (Not applicable for HMSA Choice and Control Formularies)
  • Med D

Please click on the links in the columns to the right for instructions and documentation required to support a request for a tiering exception.

Commercial Tiering Exceptions

 

Med D Tiering Exceptions

 

 

 

CVS Caremark Prior Authorization - Fax Forms

Forms are being updated and will be made available soon. In the meantime to submit a PA please visit http://www2.caremark.com/epa/ or call the numbers above.

 

 

 

Back to Top

Mail Order

Mail Order Prescription Drug Program

HMSA's Mail Order Prescription Drug Program is a convenient way for your patients to have their maintenance medications delivered directly to their home, safely and efficiently. For more information, click the link below:

 

Back to Top

Information for Pharmacies

CVS Caremark Provider Portal

For quick reference and helpful information to Caremark's Provider Portal, please check this link.

 

 

Pharmacy MAC Review

Periodically, physicians become aware of a shortage of a medication they prescribe. We encourage you to save the link below and periodically check the FDA website to stay informed of any shortages of drugs you may be prescribing.

 

 

Handbooks for Pharmacies Participating with HMSA

 

HMSA High Risk Medication Alternatives

Certain medications have been determined to carry a risk of increased adverse events in persons over 65 years of age. HMSA provides a list of common drugs that carry increased risk to our older members, and suggested formulary alternatives for these drugs.

 

HMSA Pharmacy Newsletter and Formulary Update

The HMSA Pharmacy Newsletter is distributed quarterly to all participating providers. The newsletter highlights upcoming formulary changes and benefit revisions to the HMSA formulary.

 

Back to Top

Information for Providers

CVS Caremark Provider Portal

For quick reference and helpful information to Caremark's Provider Portal, please check this link.

 

 

Pharmacies That Participate with HMSA's Medical Plans

 

 

Drug Shortages

Periodically, physicians become aware of a shortage of a medication they prescribe. We encourage you to save the link below and periodically check the FDA website to stay informed of any shortages of drugs you may be prescribing.

 

 

Handbooks for Pharmacies Participating with HMSA

 

 

HMSA Pharmacy Newsletter and Formulary Update

The HMSA Pharmacy Newsletter is distributed quarterly to all participating providers. The newsletter highlights upcoming formulary changes and benefit revisions to the HMSA formulary.

 

Back to Top

Formulary Search

Please click the link below to access the search tool:

Formularies for HMSA Medicare Plans

Back to Top

Back to Top

Back to Top

Back to Top

First Published:04/10/2013
Latest Revision:03/16/2017
Back to Top

Files that are in PDF format can be viewed using the free Adobe Reader or another PDF-reader application.

Decorative arrowsHomeNews and AlertsE-LibraryMedicare E-LibraryCommunications ArchiveQUEST IntegrationFrequently Asked QuestionsUseful Web SitesContacting HMSA