Form Instructions
Coverage Determinations
A coverage determination is HMSA’s initial decision about whether we will provide
coverage for a Part D prescription drug.
Standard decision – The timeframe we have to make a decision
after we receive your request depends on whether you have already received your
prescription drug, or you are waiting to receive your prescription drug. Refer to
the Evidence of Coverage for detailed information about the standard decision process
for a coverage determination.
Fast decision – We must notify you by telephone and in writing
of our decision within 24 hours, if you or your doctor believes that waiting for
a standard could seriously harm your health or your ability to function. Refer to
the Evidence of Coverage for detailed information about the fast decision process
for a coverage determination.
Instructions
To request a coverage determination for a prescription drug, please call Customer
Relations directly at the phone numbers listed in
Contact Information. If we can’t respond to your request over the
phone, we have a formal procedure for reviewing your request.
Prescription (Part D) drug coverage determination requests – This form, the
Drug Review Request Form, is part of the formal review process for requesting that
a particular prescription drug or prescribed treatment be covered by HMSA. Because
of the need for codes and other health system information, you will need your physician’s
assistance to complete it.
Please print out the form and complete your portion. Ask your physician to complete
the remainder and mail it to HMSA’s Medical Management department at the address
given below.
- Fill out your name, telephone numbers, birth date, gender, and HMSA number.
- Ask your physician to complete and submit the form to HMSA.
- To avoid any delays, your doctor should attach supporting documentation from your
medical record, according to HMSA’s medical policy.
- Your doctor should mail the required documents to:
HMSA
Medical Management Department
P. O. Box 2001
Honolulu, HI 96805-2001