Drug Formulary Information

This section is to be used in conjunction with the HMSA Drug Formulary and the HMSA Pharmacy Newsletter.

• The HMSA Drug Formulary is updated quarterly and includes lists of medications and supplies related to drug therapy. Organized by therapeutic class, as well as by brand name and generic name, the HMSA Drug Formulary is intended to aid physicians in their selection of drug therapy for HMSA members.
• The HMSA Pharmacy Newsletter informs providers of quarterly recommendations made by the HMSA Pharmacy and Therapeutics (P&T) Advisory Committee. The publication also highlights formulary updates, benefit revisions and claims processing issues.
• The HMSA Drug Formulary and Pharmacy Newsletters are available online in the HMSA Provider E-Library.

P&T Advisory Committee

The P&T Advisory Committee is composed of practicing physicians and pharmacists who meet quarterly. The committee is charged with maintaining the HMSA Drug Formulary, determining drug policy and ensuring clinical quality care with respect to the use of the drug formulary. Subcommittees, convened on an as-needed basis to evaluate therapeutic classes of pharmaceuticals, offer clinical expertise and make recommendations to the P&T Advisory Committee. Subcommittees are composed of community-recognized specialty physicians, practicing primary care physicians and pharmacists.

Drug Formulary Updates

Provider request

Physicians may request additions to or deletions from the HMSA Drug Formulary. Physicians who wish to make such a request must:

• Explain the reason for the request
• Suggest appropriate restrictions or guidelines for use, if applicable
• Provide reference information for literature cited in the request

The P&T Advisory Committee will consider all FDA-approved drugs for inclusion in the formulary. Requests should be submitted to:

Pharmacy and Therapeutics Advisory Committee

HMSA – Pharmacy Management

P.O. Box 860

Honolulu, HI  96808-0860

P&T Advisory Committee review criteria

The P&T Advisory Committee will determine whether the proposed drug has an FDA indication(s) that would benefit patients in an outpatient setting with a covered medical condition. The drug must also offer advantages over existing medications in the same therapeutic category. Advantages include:

• Distinct new therapeutic or pharmacological features
• Greater efficacy, as shown by well-controlled comparative clinical trials
• Better adverse effect profile, including lower frequency and diminished severity
• Fewer contraindications or precautions

P&T Advisory Committee review process

A detailed review of literature is prepared by HMSA’s Pharmacy Benefit Management for the purpose of addressing critical issues surrounding the proposed drug. Although the P&T Advisory Committee customarily reviews data published in peer-reviewed journals, the committee also relies on evidence-based decision making and will consider any evidence sufficiently detailed so as to be considered valid. The committee evaluates a proposed agent or compares agents within a therapeutic class based on the following factors:

• Efficacy and effectiveness
• Safety
• Use in specialty populations, as applicable (geriatrics, pediatrics, pregnancy, renal dysfunction, hepatic dysfunction, etc.)
• Adherence and formulation issues
• Actual or projected utilization
• Financial analysis

Implementation of decisions

To ensure that claims processing, internal education efforts and provider and member notification are accomplished, the P&T Advisory Committee decisions may take up to three months to implement.

Notification of formulary changes

Information regarding P&T Advisory Committee recommendations is disseminated via the following HMSA publications:

• The HMSA Drug Formulary is distributed or made available electronically to all participating physicians.
• The HMSA Pharmacy Newsletter is distributed quarterly.
• Letters of notification may be mailed, faxed, or made available electronically to individual providers as needed.

Determination of Copayments and Benefit Coverage

HMSA encourages physicians to prescribe drugs that are both clinically suitable and affordable for members. Most patient drug copayments vary according to the following three drug classifications:

Generic drugs

A generic drug, as defined by HMSA, is prescribed or dispensed under its commonly used generic (chemical) name and is no longer protected under patent laws. Generic drugs are generally the least expensive drugs in a particular therapeutic class and have the lowest patient copayments.

Generic substitution is a process by which a generic equivalent is dispensed rather than the brand-name drug. Most HMSA drug plans are subject to Mandatory Generic Reimbursement Program. This program requires generic substitutions for selected brand-name drugs, which have generic equivalents, found on either the Hawaii State Formulary and/or are A-rated by the FDA Approved Drug Products with Therapeutic Equivalence Evaluations. If the member chooses the brand-name drug instead of the generic equivalent, the pharmacist will collect in full for the brand-name drug. HMSA will then reimburse the member the amount that would have been paid as a benefit for the generic equivalent.

Preferred drugs

Preferred drugs are brand-name drugs for which HMSA members make fixed copayments. Copayments for Preferred drugs are lower than those for Other brand drugs.

Other brand drugs

This category refers to brand-name drugs for which copayments are variable and determined by the member’s drug plan. Copayments are higher than those for generic and preferred drugs.

General Guidelines for Drug Coverage

• Confirmation of drug coverage: Pharmacies without point-of-sale (POS) systems and providers may confirm current coverage and eligibility by calling Membership Connection at 808-948-6244 on Oahu or 1-800-552-8507 on the Neighbor Islands. Non-POS claims should be filed on a Universal Claim Form (UCF).
• Unbreakable packages: Some medication dosage forms and packages are dispensed in their original containers. These unbreakable items include eye drops, inhalers, creams, ointments, etc. The HMSA drug claims processing system generates appropriate copayment amounts for unbreakable items based on the calendar days’ supply.
• Extended absence: Members are eligible for a supply of medication for up to 90 calendar days in the event of an impending extended absence. Supplies for an extended absence may be dispensed at the direction of the prescriber or pharmacist. Multiple copayments may apply.
• Insulin and diabetic supplies: Copayments for insulin and diabetic supplies are variable and determined by the member’s drug plan. Covered diabetic supplies are limited to syringes, needles, lancets, auto-lancet devices, glucose test solution, sugar test tablets and tape, and acetone test tablets.
• Convenience packaged drugs and unit dose drugs are not covered.
• Contraceptives: Specially contracted oral contraceptives and all contraceptive devices are now covered under HMSA medical benefits; these services continue to be processed for payment under the member’s drug plan.
• Injectable Imitrex is payable.
• Anti-obesity drugs: HMSA does not provide coverage for drugs used for weight loss.
• Impotence drugs and topical agents: Orally administered impotence drugs such as yohimbine hydrochloride, and topical creams or gels containing vasodilators, including minoxidil, nitroglycerin, papaverine hydrochloride and prostaglandin E1 (alprostadil), are not a benefit of most HMSA drug plans. As an exception, the Federal Plan (coverage code 87) and HMSA Plan for Postal Service Employees covers oral drugs for treatment of erectile dysfunction.

Revision History