HMSA Formulary†,*
Select Formulary Coverage Codes
| 129 132 133 138 139 140 141 142 144 169 173 |
283 284 |
337 338 371 372 395 396 399 |
400 403 404 412 435 |
602 606 613 614 633 641 642 644 697 699 |
706 712 717 719 721 769 783 |
811 812 835 837 838 839 840 841 842 843 844 845 |
851 852 853 854 855 856 857 858 859 868 881 |
952 962 963 969 970 982 986 987 |
00A 00V |
Choice Formulary Coverage Codes
| 229 | 273 | 304 | 305 | 321 | 339 | 380 | 381 | 828 |
Limited Rx Formulary Coverage Codes
| LTDRXV (008) LTDRX2 (465) LTDRX3 (465) |
LTDRX6 (467) LTDRXA (488) LTDRXB (489) |
LTDRXC (574) LTDRXU (617) LTDRXD (760) |
LTDRXE (761) LTDRXF (762) LTDRXG (763) LTDRXH (764) LTDRXJ (765) |
LTDRXK (766) LTDRXL (770) LTDRXM (771) LTDRXN (772) LTDRXP (773) |
LTDRXQ (774) LTDRXR (775) LTDRXS (776) LTDRXO (790) LTDRXT (867) |
Childrens Formulary Coverage Code – Obsolete as of 1/1/19
| 310 |
† 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.
Access previous versions of the Select and Choice drug formulary.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |