CurrentHawaii Medical Service Association (HMSA)Policy N/A
2025 List of Covered Drugs (Dual Care Supplemental Medicaid)
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The document is the HMSA List of Covered Drugs (Formulary ID 00025219) for Dual Care Supplemental Medicaid members, describing covered prescription and OTC drugs, non-drug products, and any coverage rules or restrictions.
Policy Summary
PayerHawaii Medical Service Association (HMSA)
Policy2025 List of Covered Drugs (Dual Care Supplemental Medicaid)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2025
Last ReviewOct 1, 2025
Next Review Date
Key ActionSubmit a prescriber supporting statement when requesting an exception; HMSA will decide within 72 hours (24 hours if expedited).
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
00025219 v17Formulary ID / version
Dual Care SupplementalPlan population
PA / QL / ST / NMCommon UM flags
30dTemporary transition supply
2025Formulary year
Coverage Criteria and Formulary Controls
Coverage and Transition Conditions
Covered when ALL of the following are met
Core coverage conditions: Drug is listed on HMSA's List of Covered Drugs, the prescriber supports that the drug is medically necessary for the member, and the prescription is filled at a HMSA network pharmacy.
From overview of covered drugs and network pharmacy requirement (B1).
Temporary transition supply for new members: New members may receive a temporary 30-day supply of a nonformulary or restricted Part D drug at a network pharmacy during the first 90 days of enrollment while a formulary exception or treatment decision is pursued.first 90 days
Transition policy: 30-day supply (31 days for long-term care residents); applies only to Part D drugs purchased at network pharmacies.
Transition for long‑term care or level‑of‑care changes: Current members entering long‑term care or experiencing a level‑of‑care change may receive a temporary 31-day transition supply (and may receive more than one refill during the first 90 days in specific scenarios) of nonformulary drugs or drugs no longer covered in the new setting.
Applies to LTC residents and certain level-of-care changes; see transition policy details.
Coverage summary
Member access and coverage rules summarized
Exception processing: After HMSA receives a prescriber statement supporting an exception request, a coverage decision will be made within 72 hours; if the prescriber indicates waiting may harm the member, an expedited decision will be made within 24 hours.72h/24h
Requests may be verbal or written via the pharmacy benefit manager (B12).
Supply limits: Mail‑order and some retail programs may provide up to a 100‑day supply; a 100‑day supply has the same copay as a one‑month supply.100‑day
Mail‑order program described (B17).
Copay policy: Members have $0 copayments for prescriptions, OTC and covered non‑drug products when program rules are followed.$0
Member cost sharing described (B19).
Usage codes and controls: Drugs in the List include utilization flags (PA, QL, ST, NM, BID) that impose prior authorization, quantity limits, step therapy, mail‑order availability restrictions, or Part B/Part D determination requirements; coverage is governed by the annotations on each drug line.codes
See section C1 and individual drug rows for exact limits and requirements (C1).
Formulary coverage controls
Coverage and utilization controls as listed for individual drugs
Formulary controls: Each drug line is annotated with necessary action codes (PA, QL, ST, NM, BID) — coverage is subject to meeting prior authorization requirements, not exceeding specified quantity limits, and following step‑therapy edits where indicated.
Legend and examples shown in C1 and product rows; specific clinical PA criteria are not included in this excerpt.
Formulary utilization controls (PA, QL, ST, NM) for listed antiviral agents
Coverage and utilization controls for specific antiviral products as listed
Prior authorization: Specific antiviral and antiretroviral products are marked 'PA' or 'NM PA', indicating prior authorization is required before coverage (examples in this segment include EPCLUSA PAK/TAB, HARVONI PAK/TAB, MAVYRET PAK/TAB, PEGASYS SOLN, LIVTENCITY, PAXLOVID and others).
Presence of 'PA' or 'NM PA' on product row signals PA requirement; exact PA clinical criteria are maintained in the PA process, not in this excerpt.
Quantity limits: Several antiviral products carry quantity limits (QL) with numeric limits shown on the drug line (examples: LIVTENCITY TABS 200mg QL (336 tabs/28 days); PAXLOVID PAK QL (22 tabs); NUZYRA TABS 150mg QL (30 tabs/14 days); INQOVI/LONSURF QL entries).see product line
Numeric QL values are listed next to affected products where shown.
Step therapy: Some antiviral agents or associated classes are designated 'ST' indicating a step therapy requirement applies; specific prerequisite agents or step sequences are not detailed in this excerpt.
ST flag appears in headers and individual entries (C1/antiviral section).
Availability flags (NM/NM PA): 'NM' and 'NM PA' annotations appear for multiple antiviral products indicating limited availability or mail‑order restrictions and that PA may be required for certain formulations or pack sizes.
NM/NM PA used as availability/coverage flags in the formulary extract.
Coverage when UM flags present
Coverage and utilization management indicated by flags for listed drugs (examples below reflect the fragment):
Apply UM flags shown on drug line: If a drug entry displays PA, QL, or ST, coverage is contingent on meeting those program requirements: submit prior authorization when PA is required, do not exceed quantity limits (QL), and follow step therapy (ST) edits when present.
Derived from multiple drug rows and C1 legend showing PA/QL/ST flags; PA may also be triggered after large supplies or specific conditions (see product rows).
Coverage conditioned on product-specific edits
Coverage and access are conditioned on per-product edits shown (quantity limits, prior authorization, step therapy).
Product‑specific edits govern coverage: Coverage for each listed product is subject to the specific edit(s) shown on its drug line (examples include QL, PA, QL PA, or QL NM PA). If 'PA' or 'QL PA' is indicated, prior authorization must be obtained; if 'QL NM PA' is indicated the product may be considered not available at mail order or not medically necessary absent PA.see product line
Providers must request PA where indicated and provide documentation to justify quantities above QL or to overcome NM determinations.
Age-based PA
Age-based prior authorization conditions apply for some medications.
Age‑based PA triggers: Certain medications have prior authorization applied based on patient age (examples in the listing: PA applies for memantine formulations if patient is 29 years and younger; PA applies for some hypnotics and sedatives if patient is 65 or 70 years and older; PA applies for select oral liquids and large supplies for older adults).age >= specified age on product line
Age thresholds and PA triggers are indicated on specific product rows (see memantine, temazepam, zaleplon, eszopiclone, diazepam entries).
The formulary transition policy applies only to Medicare Part D drugs that are purchased at an HMSA network pharmacy. New members may receive temporary transition fills for Part D drugs during the first 90 days of enrollment (typically a 30‑day supply; 31 days for long‑term care residents in applicable scenarios) while pursuing a formulary exception or change. The transition process does not apply to non‑Part D drugs or to drugs obtained out‑of‑network unless the member qualifies for out‑of‑network access.
Drugs that are identified in the List of Covered Drugs as non‑Part D follow different administrative and appeals pathways than Part D drugs. The listing highlights that non‑Part D items have distinct rules for appeals and coverage; members and prescribers should consult the Evidence of Coverage and contact Customer Relations for appeal procedures when a non‑Part D coverage decision is disputed.
Some formulary entries are annotated NM, which in this listing is used as an availability flag indicating the item is not available via mail‑order or otherwise designated as not available through that channel. The document fragment does not provide further exclusion logic beyond the availability indication for those NM‑flagged items.
Within the drug table, lines marked NM indicate the product is not available through mail‑order or is designated as not available via that channel; many products carry combined flags such as NM PA when availability restrictions are paired with a prior authorization requirement.
Several drug entries show NM or combined flags such as NM PA, denoting that the product is not available at mail‑order and that prior authorization may also be required. These combined flags identify restricted availability and administrative requirements for the affected products.
Items annotated NM or compound flags like QL NM PA in the drug list are presented as potentially not medically necessary or not available at mail order unless an authorization/override is granted. The listing uses these flags to indicate that coverage may require prior authorization to override availability or NM determinations.
Certain branded products are explicitly noted as not covered when a particular brand is referenced (for example, RELION‑branded NOVOLIN and NOVOLOG products are indicated as not covered in the listing). Providers should confirm acceptable brand/generic options when dispensing insulin or other affected products.
The NM flag is used repeatedly to denote products that are not available via mail‑order; some of these items are combined with other flags (for example, NM PA) to indicate both restricted availability and that prior authorization is required for coverage or exception.
The document fragment does not define clinical criteria that render a product explicitly “Not Medically Necessary.” Instead, the label NM functions as a coverage/availability flag within the drug list and appears in combination with other utilization controls (e.g., QL, PA) rather than as standalone clinical NM criteria.
Multiple products in the listing are flagged with NM or combined annotations such as QL NM PA, signaling that those items may be considered not medically necessary or not available through standard channels unless the prior authorization and any quantity‑limit criteria are satisfied. Providers should submit PA documentation where indicated to request coverage despite NM flags.
Utilization Codes and Quantity Examples
Utilization Codes in Drug Listmixed
| PA | Prior Authorization |
| QL | Quantity Limits |
| ST | Step Therapy |
| NM | Not Available at Mail Order |
| BID | B or D: may be covered under Medicare Part B or D depending upon the circumstances |
Formulary drug entries (no billing codes in excerpt)mixed
| No codes listed |
Drugs listed (no billing codes in this fragment)mixed
| none | No explicit CPT/HCPCS/ICD codes present in this fragment; entries are drug names and formulations. |
No explicit procedure/diagnosis codes in this segmentmixed
| No codes listed |
inv-22: Quantity limits examples
ColchicineQL — 60 caps per 30 days (6 mg) or QL — 120 tabs per 30 days (0.6 mg)
Fentanyl patchQL — 10 patches per 30 days (example strength 100 mcg/hr)
Oxycodone solutionQL — 900 mL per 30 days
Naproxen (various formulations)Examples include QL — 120 tabs per 30 days and QL — 90 tabs per 30 days depending on formulation
inv-23: Quantity Limits examples
Oxycodone (tabs)QL — 180 tabs per 30 days (example for specified strengths)
Oxycodone solution / large-volume liquidsQL — 900 mL per 30 days
Selected opioid/tablet entriesExamples include QL — 60 tabs per 30 days for some formulations
inv-24: Quantity limits examples
General oral tablet QLsExamples shown: QL — 30 tabs per 30 days (some agents)
Capsule QLsExamples shown: QL — 120 caps per 30 days (multiple agents)
High-count tablet QLsExamples shown: QL — 240 tabs per 30 days for selected agents
inv-25: Quantity limits examples
Common tablet limitsQL — 120 tabs per 30 days (example product listings)
Smaller tablet limitsQL — 60 tabs per 30 days (example product listings)
Oral solution limitsQL — 900 mL per 30 days (example liquid formulations)
Pack-specific QLQL — 28 tabs per 28 days (example for certain pack/pak products)
Prior Authorization, Step Therapy, Documentation and Denial Risks
Prior Authorization
Prior Authorization Required / Coverage Verification
HMSA's List of Covered Drugs indicates when prior authorization (PA), step therapy (ST), quantity limits (QL), or mail-order restrictions (NM) apply. Some drugs require PA before dispensing; claims may be denied if PA is not obtained. The formulary can change at any time and coverage depends on plan contracts and renewals. CVS Caremark manages pharmacy benefits for HMSA and can be contacted to verify coverage and request authorizations or exceptions.
- The List shows per-drug flags: PA = Prior Authorization required; QL = Quantity Limits; ST = Step Therapy; NM = Not available at mail order; BID = May be covered under Medicare Part B or D.
- Some specialty agents and antiviral combination products (examples: EPCLUSA, HARVONI, MAVYRET, MAVYRET PAK, MAVYRET TAB, EPCLUSA TAB, LIVTENCITY, MAVYRET PAK) are labeled NM PA or PA — prescribers must submit PA before fill.
- PA flags (PA, NM PA, QL NM PA) indicate prior authorization is required and may include additional documentation such as diagnosis, quantity justification, or age-based justification.
- Certain IV and oral anti-infectives and antifungals (e.g., imipenem-cilastatin IV, voriconazole) and selected oncology, neurology, and specialty agents are subject to PA and/or QL.
- Age-based PA: some products require PA for older or younger patients (examples: memantine PA applies if patient is 29 years and younger; guanfacine PA applies if 70+; benzodiazepine liquids or high-volume supplies may trigger PA if patient is 65+).
- Mail-order restrictions: 'NM' indicates not available at mail order; 'NM PA' or 'QL NM PA' indicate a product is not available by mail and requires PA.
- Step therapy (ST) appears for multiple classes (antivirals, antipsychotics, antiseizure agents, some cardiovascular and endocrine agents). When ST is indicated you or your prescriber may need to try specified first-line drugs before coverage of alternatives.
- Exception requests: Members, prescribers, or authorized representatives can request exceptions to coverage rules (including PA or ST) — after prescriber supporting statement, standard decision within 72 hours; expedited (if harm likely) within 24 hours.
- How to verify coverage: check the up-to-date List online at hmsa.com/advantage or call HMSA/CVS Caremark at the numbers on the document for PA, exception, and coverage decision processes.
- Documentation expectations: submit prescriber supporting statement, diagnosis, quantity and medical justification, and any age-based rationale when requesting PA or QL exceptions; 90-day supply rules may trigger PA for some products.
- Denial risks: failure to obtain required PA, exceed QL, ignore mail-order restrictions, or not follow ST pathways may lead to claim denial; non-Part D drugs follow different appeals rules and may be denied under Part D processes.
- Operational notes: PA may apply after a 90-day supply in a calendar year for some agents; some PA requirements vary by formulation, supply size, or patient age.
- Contacts and process: To request coverage determinations or check status call HMSA's PBM at 1 (855) 479-3659 (TTY 711) or HMSA Customer Relations at (808) 948-6000 or (800) 660-4672; forms also available at hmsa.com/help-center/forms/medicare-drug-review1.
Denial Risk
Provider Actions to Reduce Denial Risk
Actions to avoid denials and speed approvals: verify current formulary flags before prescribing/dispensing, obtain required PA before fill when the drug line shows a PA/NM PA flag, adhere to QL and ST rules, and include clear supporting documentation with PA requests (diagnosis, prior drug trials, quantity and age justification). If coverage is needed but a rule prevents access, consider submitting an exception request with prescriber justification.
- If PA is indicated on the drug line, the prescriber must submit the PA; claims may be rejected without it.
- For quantity limit exceptions, include quantity/pack-size specifics and clinical rationale; ensure claim matches requested pack/size.
- When step therapy is indicated (ST flag), document prior trials of required agents or request an exception explaining why first-line agents are inappropriate.
- For age-based PA triggers, include patient age and clinical justification when requesting PA for large supplies or restricted agents.
- Expedited exceptions: request if waiting 72 hours could harm the patient; prescriber's supporting statement required for 24-hour review.
Documentation Required
Documentation Requirements for PA/QL/Exceptions
Documentation is required with many PA and exception requests. Provide the clinical diagnosis, prior therapy history, quantity requested with rationale, and any patient-specific factors (age, comorbidities). The List annotates when supporting documentation is expected (QL NM PA, NM PA, PA).
- Include diagnosis and quantity justification when PA or QL exceptions are requested.
- For specialty and oncology agents flagged QL NM PA, include treatment plan, dose, and justification for pack/supply sizes.
- Prescribers must submit supporting statements for exception requests; standard decisions within 72 hours, expedited within 24 hours if clinically necessary.
Step Therapy
Step Therapy (ST) — Provider Steps
Step therapy rules apply where the ST flag appears. Providers should follow the specified ST pathway or document why first-line agents are unsuitable to request an exception.
- ST indicates required trials of specified agents before covering alternative therapy;
- ST is used across antivirals, antipsychotics, antiseizure agents, and other classes — check the drug line for ST designation.
- Exceptions to ST can be requested with prescriber support if first-line drugs are contraindicated or ineffective.
Formulary Background and Scope
Administrative sections of the formulary (Table of Contents, disclaimers, member‑facing information) are included in this document and are intended for plan members and providers. These sections do not contain clinical medical‑necessity criteria; they provide program descriptions, access instructions, and legal/disclaimer material for the Dual Care Supplemental Medicaid formulary.
Key Definitions and Legend
inv-88: List of Covered Drugs — Definition (Member-facing)
DefinitionList of Covered Drugs (Drug List): a document that tells which prescription drugs, OTC drugs, and non-drug products/items are covered by HMSA and whether there are rules or restrictions.
PurposeIndicates coverage, formulary status, and any utilization controls (PA, QL, ST, NM, BID)
Where to accessUp-to-date Drug List posted online at hmsa.com/advantage (monthly updates) and available by phone
inv-89: List of Covered Drugs / Index / Abbreviations
Organized indexThe formulary includes an Index of Covered Drugs and abbreviations (see Abbreviations location referenced in the Table of Contents).
Table of Contents referenceList organized by medical condition with an index and abbreviations (TOC entries point to C1, D index).
Abbreviations locationAbbreviations for the formulary appear in the referenced pages (e.g., xvi).
inv-90: Generic drugs — definition and substitution notes
Definition of generic drugsGeneric drugs contain the same active ingredients as brand-name drugs, are FDA‑approved, typically lower cost, and may be substituted at the pharmacy per state law.
Substitution noteGeneric substitution may occur without a new prescription depending on state law; both brand and generic are covered by HMSA.
Cost implicationGeneric drugs usually cost less than brand-name counterparts and are considered therapeutically equivalent in most cases.
inv-91: Generic drugs — therapeutic equivalence and cost notes
Therapeutic equivalenceGenerics generally work just as well as brand-name drugs and are considered therapeutically equivalent.
Coverage stanceHMSA covers both brand-name and generic drugs; substitution follows applicable pharmacy/state rules.
Provider actionPharmacy may substitute generic for brand depending on state law and prescription provisions.
inv-92: Biological products / Biosimilars — biosimilar substitution and interchangeability
DefinitionBiological products are complex drugs; biosimilars are highly similar alternatives to original biological products.
InterchangeabilitySome biosimilars are designated interchangeable and, depending on state law, may be substituted at the pharmacy without a new prescription.
Coverage implicationBiosimilars may offer lower cost alternatives to original biologics and are treated per regulatory and state substitution rules.
inv-93: OTC / non-drug OTC — coverage of OTC and non-drug items when prescribed
OTC drugs coverageSome over-the-counter (OTC) drugs are covered when prescribed by a provider and listed on the Drug List.
Non-drug OTC itemsCertain non-drug OTC products (e.g., gauze pads, adhesive bandages, peak flow meters) are covered when prescribed by a provider.
Where to find detailsSee the Drug List for the specific OTC and non-drug items that HMSA covers.
inv-94: QL — Quantity Limit definition
DefinitionQL (Quantity Limit): the maximum quantity covered for the specified time period as noted (e.g., QL (180 tabs 30 days)).
Typical periodQuantity limits are commonly specified per 28–30 day supply; some pack-specific QLs use 28‑day wording.
Provider implicationClaims exceeding QL may require prior authorization or be denied; documentation should support requests for larger quantities.
inv-95: PA — Prior Authorization definition
DefinitionPA (Prior Authorization): pre-approval required from HMSA before the listed drug/formulation will be covered.
When appliesPA flags appear next to products in the Drug List (e.g., NM PA, QL PA) and must be obtained to avoid denial.
DocumentationPrescriber must submit supporting documentation for exception/PA requests; standard decision timeframe is 72 hours, expedited 24 hours with prescriber statement.
inv-96: ST — Step Therapy definition
DefinitionST (Step Therapy): a requirement that specified preferred/step agents be tried before the requested drug will be approved.
Where shownST flags appear in the Drug List adjacent to product or group headings; specific step sequences are available in plan materials or PA pathways.
Provider actionProviders may request exceptions if first‑line therapy is not appropriate; supporting documentation is required for exceptions.
inv-97: NM — Not available at mail-order or Not Marketed definition
MeaningNM — Not available at mail-order or Not Marketed: indicates limited availability or not supplied via mail-order; may also appear combined with PA flags (NM PA).
Coverage impactItems marked NM may require pharmacy fulfillment at network retail or be unavailable through mail-order; claims via mail-order may be denied for NM items.
Combination flagsNM combined with PA or QL (e.g., QL NM PA) signals both availability restriction and requirement for prior authorization to override coverage limits.
inv-98: PA legend entry
Legend: PA'PA' indicates Prior Authorization (pre-approval required before coverage).
UsagePA appears next to product lines in the Drug List to signal PA requirement before dispensing.
Provider noteObtain PA where indicated to avoid claim denials; PA documentation guidance is available in plan materials.
inv-99: QL legend entry
Legend: QL'QL' indicates Quantity Limits (maximum quantity allowed for the specified time period).
Typical formatShown as QL (count days) e.g., QL (30 tabs 30 days) or QL (336 tabs 28 days).
Claims implicationClaims exceeding the listed QL may require PA or be denied unless justified and authorized.
inv-100: ST legend entry
Legend: ST'ST' indicates Step Therapy — member must try specified first-line agents before the requested drug is covered.
Where to checkWhen ST appears, consult plan step therapy pathways or PA instructions for specifics.
Exception processProviders can request exceptions with prescriber documentation stating prior therapy intolerance or failure.
inv-101: NM legend entry — Not available at mailorder or Not marketed
NM (mail-order) meaning'NM' indicates Not available at mail-order or Not marketed; may restrict mail-order fulfillment for the product.
Coverage consequenceProducts flagged NM may be available only at network retail pharmacies or specialist sites; verify fulfillment options before submitting claims.
Combined flagsWhen combined with PA or QL (e.g., QL NM PA), NM signals both availability restriction and additional utilization management requirements.
inv-102: BID — legend/flag meaning (B or D)
BID flag meaning'BID' used in the formulary as an availability/coverage flag meaning Covered under Medicare B or D (or can denote dosing frequency depending on context).
Site/payment noteBID entries may indicate that coverage/payment source (Part B vs Part D) depends on administration setting and billing rules.
Provider actionConfirm Part B vs Part D determination for BID‑flagged products when billing for administration or infusion services.
inv-103: QL — Quantity Limits per 28–30 days
Typical QL periodQuantity Limits commonly specify a maximum supply per 28–30 day period (e.g., QL (30 tabs 30 days)).
Pack-specific QLsSome products use 28‑day pack limits (e.g., XCOPRI PAK entries) rather than 30‑day wording.
ImplicationProviders should match claim days’ supply and pack size to the QL to avoid edit/denial; request PA for quantities beyond QL.
inv-104: PA — Prior authorization required before coverage
PA — pre-approval requirementPrior Authorization must be obtained before coverage is approved when 'PA' is indicated next to a product.
Failure to obtain PAIf PA is required and not obtained, HMSA may deny coverage for the drug claim.
How to requestSubmit prescriber supporting statement and clinical documentation via the pharmacy benefit manager; standard decision 72 hours, expedited 24 hours.
inv-105: NM — Not available at mail-order
NM — mail-order not available'NM' indicates the product is not available at mail-order; members must obtain the product at a network retail or specialty pharmacy as indicated.
ExamplesSome injectables, specialty kits, and certain branded products are flagged NM or QL NM PA indicating restricted availability at mail-order.
Provider actionVerify fulfillment channel (retail vs mail) when NM flag appears to avoid claim/payment issues.
inv-106: ST — Step Therapy shorthand
ST shorthand'ST' flag in the Drug List indicates Step Therapy applies to that drug or class — member must trial required agents first.
Where listedST appears adjacent to group headings and individual products where step edits are enforced.
ExceptionsProviders may request exceptions with documentation when step therapy is contraindicated or ineffective.
inv-107: QL — Quantity Limit examples and definition
Definition & examplesQuantity Limits (QL) cap the quantity dispensed per time period; examples in the Drug List include counts like 180 tabs/30 days, 900 mL/30 days, 60 tabs/30 days depending on product.
Pack vs day-supplySome QLs reflect pack sizes or specific day-supply units (e.g., 28‑day pack counts) rather than a generic 30‑day phrasing.
Claims/documentationPrescribers should document and request PA when quantities above the QL are clinically necessary.
inv-108: PA — Prior Authorization definition (reiterated)
Prior Authorization (PA)Prior Authorization requires prescriber submission and HMSA approval before the drug is covered when 'PA' is shown next to the product.
Decision timeframesStandard PA/exception decision: 72 hours; expedited decisions when prescriber states harm: 24 hours.
How to submitRequests can be verbal or written via the pharmacy benefit manager (CVS Caremark) as noted in plan materials.
inv-109: NM — Not available at mail-order flag (reiterated)
NM (mail-order) flag'NM' indicates Not available at mail-order — product fulfillment is restricted (may be available only at retail or specialty pharmacies).
ExamplesOMNIPOD kits/pods and some specialty injectables are flagged with QL and NM PA indicating mail-order restrictions.
Provider verificationCheck the Drug List entry to confirm whether mail-order fulfillment is allowed or if retail/specialty dispensing is required.
inv-110: ST — Step Therapy legend (reiterated)
ST (Step Therapy) legend'ST' next to a drug or group indicates step therapy applies; specific prerequisites are found in plan step therapy pathways.
Provider actionDocument prior trials or reasons for exception when requesting coverage that bypasses step therapy.
Where usedST appears across multiple therapeutic sections including antipsychotics, antivirals, and antidiabetics in the Drug List.
inv-111: QL — Quantity Limits examples (reiterated)
QL examples summaryThe Drug List shows numerous QL examples such as QL (180 tabs/30 days), QL (900 mL/30 days), QL (60 caps/30 days), QL (360 tabs/30 days).
Variation by formulationQuantity limits vary by formulation (tabs, caps, mL, syringes, pens) and are specified per product line.
AdjustmentsHMSA may change QLs during the year following Medicare/Medicaid rules; updates posted monthly online.
inv-112: PA — Prior Authorization (reiterated)
PA definition (reiterated)'PA' indicates Prior Authorization — pre-approval required before coverage for the listed drug/formulation.
Effect of no PACoverage may be denied if PA is required and not obtained before dispensing.
Submission notesProviders submit PA requests via the pharmacy benefit manager with supporting clinical documentation.
inv-113: ST — Step Therapy (reiterated)
NM flag (reiterated)'NM' indicates Not available at mail-order — fulfillment restricted; may be combined with PA or QL flags.
ExamplesMultiple specialty injectables and device kits are marked NM or QL NM PA indicating restricted channels.
ActionConfirm dispensing channel when NM appears to avoid mail-order claim denials.
inv-116: NM — Not Medically Necessary flag used in combination with QL/PA
QL NM PA meaning'QL NM PA' indicates a product has a Quantity Limit, is Not available at mail-order (NM), and requires Prior Authorization to override restrictions — clinical justification required.
Coverage implicationItems with QL NM PA may be considered not medically necessary without PA documentation and are subject to availability restrictions.
Provider stepSubmit PA with documentation to request coverage or larger quantities when QL NM PA is shown.
inv-117: QL — Quantity Limits examples (Omnipod, Prolia)
Omnipod examplesOMNIPOD pods: QL — 15 pods per 30 days (or QL — 1 kit per year for kit entries); some Omnipod kits flagged QL PA.
Prolia examplePROLIA 60 mg/ml: QL — 1 syringe (specified period e.g., 180 days depending on entry)
Other device/pen examplesExamples in the list include QL counts for pens and kits (e.g., SOLIQUA INJ QL — 5 pens/25 days).
inv-118: PA — Prior Authorization (reiterated)
PA definition (final reiteration)Prior Authorization requires approval from HMSA before the drug is covered when 'PA' is indicated; providers must obtain PA to avoid denials.
DocumentationPA requests should include prescriber supporting statement and any clinical justification; decision timeframes: 72h standard, 24h expedited.
Where to find formsPA and exception submission instructions are provided via the pharmacy benefit manager (CVS Caremark) and on the plan website.
inv-119: NM — Not available at mail - indicates product not available through mail-order
NM — mail-order not available (reiterated)'NM' indicates product not available through mail-order (flag appears across specialty/device listings).
Provider verificationConfirm retail/specialty dispensing requirements for NM items before arranging supply or submission.
Combination flagsNM frequently appears combined with PA and/or QL to indicate additional utilization management and restricted availability.
inv-120: ST — Step Therapy legend (reiterated)
ST — Step Therapy (reiterated)Step Therapy (ST) requires trial of specified first‑line agents before coverage of another drug when ST is indicated.
Where indicatedST flags appear in the Drug List at group headings and individual lines; follow payer ST pathways when present.
Exception processProviders can request exceptions with documentation that first-line therapy is inappropriate or ineffective.
Step Therapy Flags and Affected Agents
| Topic | Guidance |
|---|---|
| FAQ reference | The FAQ acknowledges that HMSA may change rules about authorization, quantity limits, and therapy restrictions and that prior step or therapy restrictions may apply to some drugs; details are shown in the drug tables (see section C1). |
| Requirement | What providers/members should know |
|---|---|
| Step therapy may be required | Members may be required to try specified first-line drugs in a defined order before HMSA will cover an alternative agent; prescribers may request an exception with a supporting statement. |
| Applicability | Action |
|---|---|
| Where ST is noted in the drug list | Step therapy applies — members must follow the ST requirements shown in the List of Covered Drugs for that product. |
| Scope | Note |
|---|---|
| Antiviral and related agents | Some antiviral agents and antiretroviral combination products are designated with ST in the drug tables; the excerpt flags ST presence but does not list prerequisite agents or sequences. |
| Flag | Interpretation |
|---|---|
| ST next to agent or class headings | Entries marked 'ST' indicate step therapy applies for some drugs or classes; the specific step sequence and requirements are not provided in this excerpt. |
| Annotation | Meaning |
|---|---|
| Entries annotated 'ST' | An 'ST' annotation in the formulary indicates that step therapy rules apply to that product; specific step details must be obtained from HMSA/CVS Caremark processes. |
| Legend flag | Implication |
|---|---|
| 'ST' present in legend | The legend defines 'ST' as Step Therapy — when present providers and members must follow the step therapy pathway indicated for the product. Specific step edit rules are not included in this extract. |
| When ST applies | Provider action |
|---|---|
| Selected listed products flagged 'ST' | Follow the payer's step therapy pathway when a product is flagged ST; document prior step completion or request an exception per HMSA guidance. |
| Examples | Formulary note |
|---|---|
| Oral and injectable antipsychotics and antiseizure agents | Multiple antipsychotics and antiseizure agents (for example, olanzapine, risperidone products, quetiapine, lamotrigine, lacosamide) include 'ST' designations in the listing indicating step therapy applies. |
| Application | Effect |
|---|---|
| Select agents/categories marked 'ST' | Step therapy is applied to select agents or categories as indicated by 'ST' or 'Step Therapy' flags; providers must follow applicable step edits. |
| Classes affected | Guidance |
|---|---|
| Antidiabetic and other drug classes | Some antidiabetic classes and other drug groups are noted with 'ST' adjacent to group headings, indicating step therapy applies; specific step sequences are not shown in this excerpt. |
| Provider obligation | Required follow-up |
|---|---|
| 'ST' next to individual products | When 'ST' appears next to items, step therapy applies and providers must follow the applicable step edits or submit an exception per HMSA/CVS Caremark processes. |
Quantity Limits by Product (Selected Examples)
inv-133: unspecified — HMSA may set quantity limits; amount allowed varies and may be changed
HMSA may set QLsHMSA may set quantity limits; the amount allowed varies by product and may be changed during the year following Medicare/Medicaid rules.
Updates postedDrug List updates (including QL changes) are posted monthly on hmsa.com/advantage.
Provider implicationProviders should verify current QLs online before prescribing/dispensing and request PA when larger quantities are clinically necessary.
inv-134: colchicine — 60 caps per 30 days (6 mg) or 120 tabs per 30 days (0.6 mg)
Colchicine QLsColchicine CAPS: QL — 60 caps per 30 days (6 mg); Colchicine TABS 0.6 mg: QL — 120 tabs per 30 days.
Formulation noteBoth capsule and tablet forms are listed with distinct QLs (caps vs tabs) in the Drug List.
Provider actionMatch claim quantity and days' supply to the listed QL; request PA if greater quantity is clinically required.
inv-135: fentanyl patch — 10 patches per 30 days (example strength 100 mcg/hr)
Fentanyl patch QLFentanyl patches: QL — 10 patches per 30 days (example entry includes 100 mcg/hr as an example strength).
Patch strengthsMultiple patch strengths are listed; QL applies to patch count per 30 days.
Provider implicationEnsure patch count per fill aligns with QL to avoid claim edits; request PA when clinically necessary to exceed QL.
inv-136: oxycodone solution — 900 mL per 30 days
Oxycodone solution QLOxycodone HCl oral solution: QL — 900 mL per 30 days.
Oxycodone tabletsOxycodone tablets shown with QL — 180 tabs per 30 days for multiple strengths (see tablet entries).
Claims noteLarge-volume liquids are subject to QL and may trigger PA for older adults or when exceeding multi‑month supplies.
inv-137: naproxen (various formulations) — examples include QL (120 tabs/30 days) and QL (90 tabs/30 days)
Naproxen QLsNaproxen formulations: examples include QL — 120 tabs per 30 days (some strengths) and QL — 90 tabs per 30 days for other formulations.
Multiple formulationsDifferent naproxen formulations (regular, delayed-release) show varying QLs by strength/formulation.
Provider checkVerify the specific naproxen line in the Drug List to confirm the exact QL for the prescribed formulation.
inv-138: multiple listed — examples such as QL (180 tabs 30 days), QL (900 mL 30 days), QL (60 tabs 30 days), QL (360 tabs 30 days)
Mixed high-count examplesDrug List includes multiple QL examples inline such as QL (180 tabs/30 days), QL (900 mL/30 days), QL (60 tabs/30 days), and QL (360 tabs/30 days) for different products.
ScopeThese examples reflect tablets, capsules, and liquid formulations across therapeutic classes.
Provider actionConfirm product‑specific QL on the Drug List prior to dispensing; request PA when necessary.
inv-139: LIVTENCITY TABS 200mg — 336
LIVTENCITY TABS 200 mgQL — 336 tabs per 28 days (listed as QL (336 tabs 28 days)).
Coverage flagsEntry also annotated QL NM PA indicating quantity limit, limited availability, and prior authorization requirements.
Provider implicationObtain PA and verify pack/dispense counts to match the specified QL when prescribing LIVTENCITY.
inv-140: PAXLOVID PAK — 22
PAXLOVID PAKQL — 22 tabs per 90 days (PAXLOVID PAK QL (22 tabs 90 days)).
Tab pack QLsIndividual PAXLOVID tablet QLs also shown (e.g., PAXLOVID TAB QL 40 tabs 90 days for some strengths).
Provider noteConfirm the pack size and days' supply when filling to ensure compliance with QL limits.
inv-141: NUZYRA TABS 150mg — 30
NUZYRA TABS 150 mgQL — 30 tabs per 14 days (NUZYRA TABS 150 mg QL (30 tabs 14 days)).
Formulation noteSome antimicrobial agents have short-interval QLs (e.g., 14‑day limits) reflecting course duration.
Provider actionMatch course length and pack size to the QL; request PA if longer duration or greater quantity is necessary.
inv-142: INQOVI TAB 35-100MG — 5; LONSURF entries
INQOVI TAB 35-100 mgQL — 5 tabs per 28 days (INQOVI QL (5 tabs 28 days)).
LONSURF TAB (various strengths)QL — 80–100 tabs per 28 days depending on strength/entry.
Coverage flagsSeveral oncology agents are listed with QL NM PA indicating quantity limits plus PA and availability flags.
inv-144: FRUZAQLA CAPS — 84 caps per 28 days (some strengths 21 caps per 28 days)
FRUZAQLA CAPSQL — 84 caps per 28 days for some strengths; other strengths listed as QL — 21 caps per 28 days.
Variable QLs by strengthSome agents have different QLs depending on strength; check specific strength entry for exact limit.
Provider actionEnsure strength-specific QL is applied when processing claims or requesting PA.
inv-145: various oral agents — 28–30 day supply commonly specified
Typical days' supplyMany oral agents use a 28–30 day supply commonly specified in QLs (providers should align days' supply on claims to the QL period).
Provider implicationWhen requesting exceptions or PAs for larger supplies, support with clinical justification and expected dosing schedule.
Where to verifyCheck the specific Drug List line for the exact QL and period (28 vs 30 days) before dispensing.
inv-146: NERLYNX TABS 40mg — QL (180 tabs)
NERLYNX TABS 40 mgQL — 180 tabs (listed as QL (180 tabs)).
Coverage flagsEntry annotated with QL NM PA indicating quantity limit plus availability/PA requirements.
Provider actionObtain PA where indicated and verify tablet counts to match QL.
inv-147: TAFINLAR CAPS 50mg; 75mg — QL (120 caps 30 days)
TAFINLAR CAPS 50 mg; 75 mgQL — 120 caps per 30 days (TAFINLAR QL (120 caps 30 days)).
Coverage flagsEntries list QL NM PA for many oncology agents indicating limits and PA requirements.
Provider actionConfirm strength and QL when prescribing TAFINLAR and request PA as required.
inv-148: ZELBORAF TABS 240mg — QL (240 tabs)
ZELBORAF TABS 240 mgQL — 240 tabs (listed as QL (240 tabs)).
Pack/periodConfirm the intended days' supply and tablet strength to ensure matching to the QL entry.
Provider actionPA may be required for some oncology agents; follow PA submission instructions when necessary.
inv-149: ENTRESTO CAP 6-6MG; 15-16MG — QL (240 caps 30 days)
ENTRESTO CAPS 6-6 mg; 15-16 mgQL — 240 caps per 30 days (ENTRESTO QL (240 caps 30 days)).
Provider implicationHigh-count QL entries require matching claim quantity and may prompt PA requests for larger supplies.
Where to verifyRefer to the Drug List line for ENTRESTO to confirm exact strength-specific QL before dispensing.
inv-150: sildenafil (pulmonary hypertension) — QL (360 tabs 30 days)
Sildenafil (pulmonary hypertension)QL — 360 tabs per 30 days (sildenafil for PAH QL (360 tabs 30 days)).
Availability/flagsEntries often include QL NM PA indicating additional availability and PA requirements for PAH agents.
Provider actionVerify QL and obtain PA where required for high-count supplies of PAH medications.
inv-151: donepezil — QL (30 tabs 30 days)
DonepezilQL — 30 tabs per 30 days (donepezil hydrochloride QL (30 tabs 30 days)).
Formulation noteOral formulations for dementia agents commonly carry 28–30 day QLs; check specific line for exact counts.
Provider actionMatch days' supply and tablet count to the stated QL; request PA only if indicated by the listing.
inv-152: INBRIJA — QL (300 caps 42mg)
INBRIJA (levodopa inhalation)QL — 300 capsules (42 mg) per listed period; entry annotated QL NM PA indicating quantity limit, availability restrictions, and PA.
Provider actionObtain PA when required and confirm pack/dispense counts to match the listed QL for INBRIJA.
Coverage implicationQL NM PA designation signals both quantity control and additional utilization management for this product.
inv-153: ABILIFY MAINTENA — QL (1 injection 28 days)
ABILIFY MAINTENA (aripiprazole depot)QL — 1 injection per 28 days (listed as QL (1 injection 28 days)).
Depot productsMany long‑acting injectables specify injection counts per 28–90 day periods (e.g., INVEGA series entries).
Provider actionEnsure administration scheduling aligns with QL and obtain PA when indicated for depot/injectable formulations.
inv-154: INVEGA HAFYERA / SUSTENNA / TRINZA — injection frequency QLs
INVEGA HAFYERAQL — 1 injection per 180 days (INVEGA HAFYERA QL (1 injection 180 days)).
INVEGA SUSTENNAQL — 28 days with specified vial counts per period (INVEGA SUSTENNA entries list 28‑day QLs).
INVEGA TRINZAQL — 90 days with specified vial counts per period (INVEGA TRINZA entries list 90‑day QLs).
inv-157: lurasidone / quetiapine examples
Lurasidone HClQL — 30 or 60 tablets per 30 days depending on strength (lurasidone entries show QL (30 tabs) and QL (60 tabs)).
Quetiapine fumarateQL — 60–90 tablets per 30 days depending on strength/formulation (listed QL ranges).
Provider actionCheck strength-specific QL when dispensing antipsychotics and antiepileptic agents to match claim quantities.
inv-158: quetiapine / risperidone solution / clobazam suspension
Quetiapine fumarateQL — 60–90 tabs per 30 days depending on strength (multiple entries list QL ranges).
Risperidone solutionQL — 240 mL per 30 days (risperidone SOLN QL (240 mL 30 days)).
Clobazam suspensionQL — 480 mL per 30 days (clobazam SUSP QL (480 mL 30 days)).
inv-159: lacosamide, diazepam, DIACOMIT examples
Lacosamide oral solutionQL — 1200 mL per 30 days (lacosamide oral SOLN QL (1200 mL 30 days)).
Diazepam solutionQL — 1200 mL per 30 days; PA applies if patient is 65+ when >5 day supply.
DIACOMIT (stiripentol)QL — 180 capsules per 30 days (DIACOMIT QL (180 caps 30 days)).
inv-166: XCOPRI and XCOPRI PAK formulations
XCOPRI formulationsQL — Pack-specific counts such as 28/30/56/60 tabs per pack; examples: XCOPRI TABS 25/50/100 QL (30 tabs/30 days) and XCOPRI TABS 150/200 QL (60 tabs).
Pack vs maintenanceSome XCOPRI PAK entries specify titration and maintenance pack sizes with distinct QLs (28 vs 56 days).
Provider noteWhen dispensing XCOPRI, ensure pack type and days' supply align with the QL pack specification.
inv-167: MS injectables (e.g., COPAXONE) and related QLs
MS injectables (COPAXONE, glatiramer)QL — syringe counts per 28–30 days (e.g., COPAXONE 20 mg/ml QL (30 syringes 30 days); 40 mg/ml QL (12 syringes 28 days)).
BETASERON KITQL — 14 syringes per 28 days (BETASERON KIT QL (14 syringes 28 days)).
KESIMPTAQL — 16 pens per 365 days (KESIMPTA QL (16 pens 365 days)).
inv-168: BETASERON KIT / COPAXONE / KESIMPTA examples
BETASERON KITQL — 14 syringes per 28 days (BETASERON KIT QL (14 syringes 28 days)).
COPAXONE 20 mg/mlQL — 30 syringes per 30 days (COPAXONE SOSY 20 mg/ml QL (30 syringes 30 days)).
KESIMPTAQL — 16 pens per 365 days (KESIMPTA QL (16 pens 365 days)).
inv-171: baclofen / armodafinil / OZEMPIC examples
Baclofen tablets 5 mgQL — 90 tabs per 30 days (baclofen QL (90 tabs 30 days)).
Armodafinil 50 mgQL — 60 tabs per 30 days (armodafinil QL (60 tabs 30 days)).
Ozempic pensQL — 1 pen per 28 days or QL — 4 pens per 28 days depending on dose; check specific entry for dose-based QL.
inv-173: CEQUR / OMNIPOD / related device QLs
CEQUR SIMPL KIT PATCH 2U (3‑DAY)QL — 10 patches per 30 days (CEQUR SIMPL KIT PATCH QL (10 patches 30 days)).
OMNIPOD pods/kitsOMNIPOD pods: QL — 15 pods per 30 days; OMNIPOD kit entries: QL — 1 kit per year for kit introductions; some kit/kit‑intro entries flagged QL PA.
Provider actionConfirm pod counts or kit frequency on the Drug List and obtain PA if the entry is QL PA.
inv-175: OMNIPOD pods — QL (15 pods 30 days) or kit/year
OMNIPOD podsQL — 15 pods per 30 days (OMNIPOD QL (15 pods 30 days)) or QL — 1 kit per year for kit entries.
OMNIPOD kit introOMNIPOD kit intro entries listed as QL — 1 (kit) (year) for initial kit supply.
Provider actionFor Omnipod supplies, match claim units to QL and request PA where QL PA is indicated.
inv-178: PROLIA 60mg/ml — 1 syringe
PROLIA 60 mg/mlQL — 1 syringe (PROLIA QL (1 syringe 180 days) as listed).
Administration frequencyInjectable bone agents often carry QLs expressed as syringe counts per specified period (e.g., 180 days).
Provider actionVerify injection schedule and obtain PA if required by the listing to ensure coverage.
inv-179: SOLIQUA INJ 100/33 — 5 pens
SOLIQUA INJ 100/33QL — 5 pens per 25 days (SOLIQUA QL (5 pens 25 days) as listed).
Pen/kit QLsMultiple pen/kit products specify QLs with non‑standard day counts (e.g., 25 days); confirm exact period per product line.
Provider actionMatch dispense quantity and days' supply to the listed QL and request PA if higher quantities are clinically indicated.
Site-of-Care and Coverage Source Notes
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Biosimilars and Interchangeability
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Policy Summary
PayerHawaii Medical Service Association (HMSA)
Policy2025 List of Covered Drugs (Dual Care Supplemental Medicaid)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2025
Last ReviewOct 1, 2025
Next Review Date
Key ActionSubmit a prescriber supporting statement when requesting an exception; HMSA will decide within 72 hours (24 hours if expedited).
SourceLink
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