Drug Review Request Form and Instructions

The Drug Review Request Form replaces the HMSA/HPH Drug Review Request Form. This form is appropriate for both private business plan members and The HMSA Plan for QUEST Members.

HMSA Select Formulary

Members may incur a differential for brand drugs that are not designated as "preferred" on the HMSA Select Formulary. For members on chronic regimens, a Drug Review Request Form may be submitted if a comparable generic or preferred brand has been tried and failed due to an adverse drug reaction or sub-therapeutic response. Upon approval of a request, the additional out-of-pocket cost to the member will be waived.

The HMSA Plan for QUEST Members

Only prescription and prescribed over-the-counter (OTC) drugs as defined in The HMSA Plan for QUEST Members are covered. Members will be required to pay for the entire cost of any medication not listed in the formulary. Members may obtain a Non-Formulary agent when a comparable Formulary agent has been tried and failed due to an adverse drug reaction or sub-therapeutic response.

Please mail or fax your completed Drug Review Request Form [PDF] to:

HMSA - Medical Management Department
P.O. Box 2001
Honolulu, HI  96805

Fax: 808-944-5618

Revision History