Why Does HMSA Have a Formulary?

HMSA embraces the concept that appropriate drug therapy is an integral part in managing patients in the outpatient setting and results in the best outcomes for our members and helps to manage the overall cost of care. However, health care costs continue to rise due to:

• Increased utilization by an aging population and more aggressive diagnosis and treatment regimens
• High costs associated with new technology
• Use of high cost brand drugs which are selected based on drug manufacturer marketing techniques of direct-to-consumer advertising and physician detailing
• A reduction in savings traditionally associated with generic drugs as demonstrated by pricing trends, generic patent strategies, and periods of ‘exclusivity’ for some of the newer generics drugs.

The State of Hawaii’s Prepaid Health Care Act requires employers to offer medical insurance to full-time employees. However, prescription drug benefits are not included in this mandate. Thus, as health care costs continue to rise, employer groups may seek to reduce associated expenses by opting for plans which offer limited drug benefits or, in the worst case, not offer drug coverage at all.

The cost of medications for members with limited or no drug coverage often hinders access to care and restricts treatment options for physicians. Thus, HMSA is committed to working closely with physicians, members, and employers to maintain a high-quality, affordable pharmacy benefit program and to help ensure that members have access to the medications they need. We believe that the appropriate use of cost-effective medications, as supported by practice guidelines, quality programs and formulary decisions is our best defense against benefit reductions.

Our approach to pharmacy management is one which incorporates benefit designs which are clinically supported by our formulary and directly tied to managed care programs which promote appropriate use of drugs.

What Is The Formulary?

The HMSA Drug Formulary is a detailed listing of medications that outlines member benefit levels (copayment levels and/or absolute coverage) for HMSA drug plans. Refer to HMSA Drug Plans for descriptions of current HMSA drug plans. The formulary:

• is a reference to assist physicians in drug therapy selection for HMSA members.
• is not intended to replace the professional judgment exercised by providers overseeing patient care.
• Applies only to outpatient prescription medications dispensed by participating providers. It does not apply to inpatient medications or medications obtained from and/or administered by a physician.
• is designed to be as comprehensive as possible, but does not list all drugs currently available in the United States
• is subject to change. Providers who utilize HMSA’s point-of-sale (POS) pharmacy claims processor have access to the most accurate and up-to-date formulary information.

New drugs, strengths, forms and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following completion of HMSA’s review process.

Revision History