QUEST Integration – Pharmacy and Drug Formulary

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

The HMSA QUEST Integration Formulary

The HMSA’s QUEST Integration Drug Formulary is designed to meet the needs of its QUEST Integration members. The formulary is managed, drives generic use, and uses over-the-counter products when possible. The formulary is fortified with selected brand drugs, which have been determined to be medically necessary when equivalent generic drugs are not available, or the brand drug offers better therapeutic outcomes or has a more favorable safety profile.

The Pharmacy and Therapeutics (P&T) Committee thoroughly reviews the safety and clinical efficacy of each drug before it gets added to the formulary and reviews each therapeutic class on the formulary. Clinical decisions are based on scientific knowledge, standards of practice, peer-reviewed medical literature, and accepted clinical practice guidelines. HMSA will cover all drugs that are mandated for coverage as set forth in their federal and state contracts, including all statutory and regulatory requirements.

The HMSA QUEST Integration Formulary is updated and serves as a guide to pharmacy drug selection for our providers and members. Drugs listed on the formulary are covered if the requirements and limits, which are included on the formulary, are met. Requirements and limits may include prior authorization, step therapy, quantity limits, age limits, diagnosis edits, mandatory generic use, or other requirements. The formulary is organized by therapeutic class and lists drugs alphabetically (by brand and generic names).

Non-Formulary Drugs

Drugs that are not listed in the HMSA QUEST Integration formulary are considered non-formulary agents. HMSA’s QUEST Integration members have access to non-formulary drugs through the non-formulary exceptions process. To view the policy, see QUEST Integration – Drug Formulary Exception.

HMSA’s Pharmacy Benefit Manager Coverage Review – Pharmacy Benefit Drugs Requiring Precertification

To request a coverage review, physicians may contact HMSA’s pharmacy benefit manager prior authorization department at 1-855-220-5732; TTY/TDD 1-800-863-5488, or by fax to 1-855-762-5206. Pharmacists and members may also initiate a coverage review, after which our pharmacy benefit manager will contact the appropriate physician’s office to complete the request.

HMSA’s pharmacy benefit manager will follow timelines set forth by the Hawaii Department of Human Services and Med-QUEST Division for an exception request and communicate all approvals and denials to the member and provider.

For reconsideration of formulary exception drugs that are denied by HMSA’s pharmacy benefit manager, a request for an appeal review may be initiated. Timelines for an appeal review will follow timelines set forth by the Hawaii Department of Human Services and Med-QUEST Division.

QUEST Integration children under the age of 21 years are covered under EPSDT. As such, they may be entitled to additional medications not included in the HMSA QUEST Integration Formulary, if medically necessary. If you feel that there are circumstances that require individual consideration, please contact HMSA’s pharmacy benefit manager.

Emergency Supply of Medication

If a prescription cannot be filled when presented to the pharmacist due to a prior authorization requirement and the prescriber’s office cannot be reached, HMSA will instruct the pharmacy to dispense a 72-hour emergency supply of the prescription. If a prescription cannot be filled when presented to the pharmacist because the drug is not on the HMSA QUEST Integration Formulary, HMSA will instruct the pharmacy to dispense a seven-day emergency supply of medication to the member until HMSA can make a medical necessity determination regarding new drugs. The pharmacy is not required to dispense an emergency supply of medication if the dispensing pharmacist determines that taking the prescribed medication would jeopardize the member’s health or safety, and they made good faith efforts to contact the prescriber.

Exclusions

Some drugs that are specifically excluded from coverage by the QUEST Integration health plan include:

• Brand drugs that have an A-rated generic equivalent, except as noted.
• Drugs used for cosmetic purposes.
• Drugs for obesity.
• Drugs for persons confined to public institutions.
• Drugs for sexual dysfunction or inadequacies.
• Drugs for the treatment of Hansen’s disease after a definitive diagnosis has been made.
• Drugs not approved by the U.S. Food and Drug Administration (FDA).
• Drugs without an indication supported in the compendia of current literature with a IIA/2A or above recommendation (e.g. Micromedex, NCCN).
• Drugs that improve physical appearance and doesn’t restore or materially improve a bodily function.
• Drugs used for baldness.
• Drugs used for infertility or to enhance fertilization.
• Experimental or investigational drugs.
• Immunizations for travel – domestic or foreign.
• Medical foods, food supplements, and prepared-formulary health foods.
• Non-formulary controlled substances used to treat pain or used as a sedative agent.

Prescribing Physicians

Non-emergency prescriptions written by providers who are not part of HMSA’s network of QUEST Integration providers are not covered.

Requests for Formulary Changes

Providers requesting addition or deletion of a drug to/from the formulary are asked to explain the reason for their request, to suggest appropriate restrictions or guidelines for use, as needed, and to provide references from the appropriate literature to be included in the review.
Further information is located in the HMSA E-library under Formularies.

Formulary Change Notification

Notifications to participating QUEST Integration providers and impacted members follow the guidelines set forth by the Hawaii Department of Human Services and Med-QUEST Division. Changes are communicated through the HMSA HealthPro News, fax blasts, and letters.

Revision History