This HMSA policy lists prescription drugs that require prior authorization (PA) before coverage. Providers, patients, or authorized representatives must request PA by calling HMSA at 1-855-479-3659 (TTY/TDD 711) before the prescription is filled; failure to obtain PA may result in denial of coverage.
For many listed agents the policy defines clinical entry criteria that must be documented with the PA request. Typical required information includes diagnosis confirmation and drug‑specific evidence such as laboratory or procedural confirmation (for example, right heart catheterization hemodynamics for pulmonary arterial hypertension), relevant mutation or genetic test results for targeted oncology agents, or microbiology/culture evidence for cystic fibrosis inhaled antimicrobials.
The document groups drugs by indication and sets both initial and continuation rules where applicable. Examples include CGRP antagonists for migraine which require an initial 3‑month trial and demonstration of reduced migraine days for continuation, FASENRA which requires baseline eosinophils ≥150 cells/µL (or systemic steroid dependence) for initiation, and HCV direct‑acting antivirals that require documented HCV RNA prior to starting therapy.
Many specialty and high‑risk medications impose prerequisite therapy or step‑therapy requirements: PA often requires documentation of inadequate response, intolerance, or contraindication to specified prior agents (for example, methotrexate or cyclosporine before certain dermatology biologics, or prior anticonvulsant trials before some antiseizure agents).
Specific diagnostic thresholds and test results are emphasized where relevant to avoid denials: for PAH new starts the policy requires right heart catheterization with pretreatment mean PAP >20 mmHg, PCWP ≤15 mmHg, and (adults) PVR ≥3 Wood units; cystinosis entries require leukocyte cystine elevation, genetic confirmation, or slit‑lamp demonstration of corneal crystals for ophthalmic products.
The policy also includes administrative exclusions and coverage‑setting rules (for example, some drugs may be covered under Medicare Part A or B rather than Part D depending on setting and administration), and lists explicit contraindications or drug–drug interaction denials such as denial of ergot or DHE agents co‑administered with potent CYP3A4 inhibitors.
Where continuation is allowed, the policy generally requires evidence of clinical benefit (for example, reduced exacerbations or steroid dose with biologics, improved symptom measures for sleep or mood disorders, or documented laboratory improvement for metabolic/hepatic conditions).
Coverage durations and special age or prescriber restrictions are specified per drug (examples: certain RSV vaccine entries show a 3‑month coverage duration; some products require specialist prescribers).
Use the individual drug entry in this policy for the exact PA phone instructions, the drug‑specific required medical information, and the precise initial and continuation criteria that must accompany a PA request.