HMSA’s Pharmacy Benefit Manager Prior Authorization

Effective Jan. 1, 2013, HMSA’s pharmacy benefit manager will be handling all the prior authorization requests for HMSA’s commercial business, QUEST Integration and Medicare Part D members.

To request a prior authorization, physicians may contact HMSA’s pharmacy benefit manager at the appropriate toll-free number listed in the table below. Physicians may also complete a prior authorization fax form and fax it to HMSA’s pharmacy benefit manager. Pharmacists may also initiate a prior authorization, after which HMSA’s pharmacy benefit manager will contact the appropriate physician’s office to complete the request.

Exceptions

Non-Formulary Exceptions (QUEST Integration, Part D, Metallic, Optimal, and Essential Prescription Formularies)

Exceptions are required for drugs that are not on the formulary. Please click on the links in the columns to the right for instructions and documentation required to support a request for a formulary exception.

• QUEST Integration Formulary Exception Criteria Fax Form [PDF]
• Med D Non-Formulary Exceptions [PDF]
• Metallic, Optimal, and Essential Prescription Non-Formulary Exceptions [PDF]
• Preventive Services Exceptions
  • Preventive Services (excluding Contraceptives) Zero Copay Exception Criteria [PDF]
  • Preventive Services Contraceptive Zero Copay Exception Criteria [PDF]

Tiering Exceptions (Commercial and Part D)

Exceptions may be reviewed to allow consideration for:

• Commercial: Higher cost OTHER BRAND drugs to be covered at Preferred Brand copays. (Not applicable for HMSA Choice and Optimal Formularies)
• Med D

Please click on the following links for instructions and documentation required to support a request for a tiering exception.

• Commercial Tiering Exceptions [PDF]
• Med D Tiering Exceptions [PDF]

HMSA’s Pharmacy Benefit Manager Prior Authorization – Fax Forms

Forms are being updated and will be made available soon. In the meantime to submit a PA please visit https://www.caremark.com/wps/portal/HEALTH_PRO_PRIOR_AUTH_INFO or call the numbers above.

• HMSA’s Pharmacy Benefit Manager Prior Authorization Forms

Revision History