Drugs That Require Prior Authorization — HMSA Akamai Advantage (PPO)
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Lists prescription drugs that require prior authorization from HMSA Akamai Advantage (PPO) and summarizes coverage criteria, required documentation, restrictions, and durations for each listed drug.
No material clinical or coverage changes in this revision.
Drug-Specific Coverage Criteria
Abiraterone (ABIRATERONE ACETATE, ABIRTEGA)
Covered when specified clinical conditions and concurrent androgen-deprivation are met
Arexvy / Abrysvo (RSV vaccines) — AREXVY and ABRYSVO
Covered for prevention of lower respiratory tract disease (LRTD) caused by RSV under vaccine‑specific constraints
Coverage duration shown for Abrysvo/Arexvy entries: 3 months.
Pulmonary arterial hypertension agents (e.g., ADEMPAS, AMBRISENTAN)
Covered when hemodynamic confirmation and, for CTEPH, surgical status are documented
Applies to PAH agents (WHO Group 1) new starts only.
ADEMPAS CTEPH-specific requirement.
Alpha1-proteinase inhibitor products (ARALAST NP, PROLASTIN-C, ZEMAIRA)
Covered when enzymatic deficiency and emphysema are documented
Applies to ARALAST NP, PROLASTIN‑C, ZEMAIRA.
Auvelity (MDD)
Covered for major depressive disorder after failure of standard antidepressants
Prerequisite therapy required.
Arcalyst (prevention of gout flares) and recurrent pericarditis
Covered when frequency and prior therapy requirements are met
For recurrent pericarditis: inadequate response/intolerance/contraindication to NSAID plus colchicine.
SLE and Lupus Nephritis PA criteria
Covered when ALL of the following are met for SLE and lupus nephritis (selected drugs):
Applies to SLE‑targeted agents requiring PA.
HAE PA criteria
Covered when ALL of the following are met for HAE acute attack treatments:
Prescribed by or in consultation with an immunology/allergy/rheumatology specialist as applicable.
BOSULIF oncology criteria
Covered when ALL of the following are met for BOSULIF in CML or Ph+ B‑ALL:
Required documentation: cytogenetic or molecular evidence of Ph/BCR‑ABL.
Lack of documented Ph/BCR‑ABL may lead to denial.
BRAFTOVI (BOSULIF entry) criteria
Covered when ALL of the following are met for BRAFTOVI (as listed):
BIMZELX criteria
Covered when ALL of the following are met for BIMZELX (new starts):
Applies to moderate‑to‑severe plaque psoriasis new starts.
Prerequisite therapy required for new starts unless specified otherwise.
CEQUR device criteria
Covered when ALL of the following are met for CEQUR starter devices:
Prescriber specialty and device training/documentation may be required.
COTELLIC coverage criteria
COTELLIC (cobimetinib) coverage conditions
Applies to melanoma and CNS indications per entry.
Cystinosis diagnostic criteria
Cystinosis therapies (CYSTADROPS, CYSTAGON, CYSTARAN) coverage conditions
Applies to ophthalmic and systemic cystinosis agents.
DALFAMPRIDINE criteria
DALFAMPRIDINE coverage conditions
Response‑based continuation requirement.
DAURISMO criteria
DAURISMO (glasdegib) coverage conditions for AML
DEFERASIROX criteria
DEFERASIROX coverage condition
Indication: chronic iron overload due to transfusions.
DHE NASAL criteria
DHE NASAL (dihydroergotamine) requirement
Concurrent potent CYP3A4 inhibitor is exclusion/denial risk.
Diazepam (older adult) criteria
Diazepam use in older adults covered under special safety acknowledgement and duration limits
Applies to cumulative therapy thresholds per HRM guidance.
DOPTELET criteria
DOPTELET (avatrombopag) criteria
For ITP: new starts require prior inadequate response/intolerance to therapies and specific platelet thresholds (e.g., <30,000/mcL) as noted in full entry.
DUPIXENT coverage criteria
DUPIXENT (dupilumab) multi‑indication criteria
Continuation requires maintained positive clinical response.
Continuation requires improved asthma control.
Continuation requires maintained clinical benefit.
EMGALITY criteria
EMGALITY (galcanezumab) coverage conditions
For episodic cluster headache initial therapy requires inadequate response/intolerance to a triptan; continuation requires 3 weeks with reduction in weekly attacks.
ENDARI criteria
ENDARI (L‑glutamine) criteria
Coverage duration: Plan Year.
GATTEX Initial Therapy
GATTEX (teduglutide) initial therapy criteria
Prescriber: gastroenterologist, GI surgeon, or nutritional support specialist preferred; continuation requires decreased parenteral support need.
FASENRA Initial and Continuation
FASENRA initial and continuation criteria
Age: asthma ≥6 years; EGPA ≥18 years.
FULPHILA Prophylaxis Criteria
FULPHILA prophylaxis criteria
Coverage duration typically 6 months for prophylactic use.
FABRAZYME Diagnostic Criteria
FABRAZYME diagnostic confirmation
Required for FABRAZYME prior authorization.
Growth Hormone Indications and Criteria
Growth hormone (GENOTROPIN) pediatric criteria
Prescribed by or in consultation with relevant specialists.
SGA age restriction: ≥2 years.
GILOTRIF (afatinib) — selected indications
GILOTRIF (afatinib) — selected indications
Prerequisite therapy required for specified indications.
Growth hormone (Genotropin) — pediatric and adult GHD
Growth hormone (Genotropin) — pediatric and adult GHD
Specialist prescribing/consultation required.
HADLIMA (adalimumab biosimilar) — rheumatologic and dermatologic indications
HADLIMA (adalimumab biosimilar) — rheumatologic and dermatologic indications
Prerequisite therapy required.
HAEGARDA (C1 inhibitor) — HAE prophylaxis
HAEGARDA (C1 inhibitor) — HAE prophylaxis
Applies to prophylactic C1 inhibitor coverage.
HER2-targeted agents — Coverage for multiple HER2-positive malignancies with disease-specific requirements
HER2-targeted agents — coverage for multiple HER2‑positive malignancies with disease‑specific requirements
Plan Year coverage duration; some biosimilar‑intolerance rules apply.
Disease‑specific combination therapy and prior HER2 inhibitor history apply (see product entries).
HERNEXEOS (HER2-targeted) — NSCLC
HERNEXEOS (HER2‑targeted) — NSCLC
Prerequisite therapy required for this NSCLC HER2‑mutant indication.
High-Risk Medications (HRM) — geriatric-specific prior authorization rules
High‑Risk Medication (HRM) groups apply additional safety checks for patients aged 65+ and require prescriber acknowledgment and, for many agents, trials of alternatives
Applies across HRM groups (anticholinergics, hypnotics, muscle relaxants, etc.).
Hydroxyzine (HRM-HYDROXYZINE) — anxiety and general rules
Covered when ALL of the following are met:
Addresses anticholinergic risk in older adults.
Zolpidem tartrate (HRM-HYPNOTICS) — alcohol withdrawal and anxiety rules
Covered when ALL of the following are met:
HRM hypnotic with alcohol withdrawal and anxiety‑specific prerequisites.
Meclizine (HRM-MECLIZINE) — insomnia alternative requirements
Covered when ALL of the following are met:
Seeks non‑HRM alternatives before HRM use in older adults.
Antihistamine for rhinitis (HRM entry)
Covered when ALL of the following are met:
Promotes non‑HRM alternatives for rhinitis in older adults.
Skeletal muscle relaxants and related agents (HRM groups)
Covered when ALL of the following are met:
General HRM caution language applied to skeletal muscle relaxants.
Selected specialty/oncology agents — indication- and prior-therapy-based coverage
Covered when specific indication‑level criteria are met (examples from the specialty/oncology segment)
See product entries for required diagnostic tests and prior treatment history.
Extended-release opioid continuation
Covered when ALL of the following are met
Prescriber should be knowledgeable in potent opioid management.
Gefitinib — EGFR-mutant NSCLC
Covered when ALL of the following are met
Covers FDA‑approved and specified medically‑accepted settings.
Isotretinoin — covered indications
Covered for listed indications
Prerequisite therapy not required unless specified in full product entry.
Ivermectin — excluded for COVID-19 use
Covered when NOT prescribed for COVID‑19
Coverage duration example: 1 month.
IVIG — specific laboratory and treatment history criteria
IVIG — specific laboratory and treatment history criteria
Coverage duration: Plan Year; indication‑specific documentation required.
Itovebi (alpelisib) — PIK3CA-mutated breast cancer
Covered when ALL of the following are met
Prerequisite therapy required.
Kalydeco — monotherapy restriction and age
Covered when ALL of the following are met
Coverage duration: Plan Year.
Kesimpta
Covered for FDA‑approved indications
Coverage duration: Plan Year.
Oral ketoconazole — safety exclusions
Not covered/contraindicated when certain conditions or interacting drugs are present
Coverage duration when approved: 6 months.
Kineret — step therapy for RA/SJIA
Covered when ALL of the following are met for certain new starts
Prerequisite therapy required.
Miscellaneous specialty drug criteria
Covered per FDA‑approved indications with drug‑specific required information where noted
See individual product sections for detailed requirements.
Per-drug PA coverage criteria
Covered when the listed PA‑required criteria or documentation are provided
Exclusion: decompensated cirrhosis/CTP class B or C.
Selected product-specific coverage criteria
Selected product‑specific coverage criteria — examples from this excerpt
Coverage duration: 6 months.
New-start criteria for select inflammatory indications
Rheumatology and dermatology biologics — new‑start examples
Applies across psoriasis biologics; prerequisite therapy often required.
Psoriasis biologic coverage criteria
Psoriasis biologic coverage criteria (repeated across agents)
Prerequisite therapy often required for several agents.
RETEVMO PA criteria
RETEVMO (selpercatinib) indication‑specific criteria
RUBRACA coverage conditions
RUBRACA (rucaparib) specified criteria in excerpt
SANTYL continuation
SANTYL continuation criteria
Coverage duration: 3 months.
Somatostatin analogs authorization
Somatostatin analogs authorization (selected example)
Prescriber specialist involvement expected.
STIVARGA colorectal cancer prerequisite
STIVARGA and related oncology prerequisites
Prerequisite therapy required.
Coverage duration: Plan Year.
SPRYCEL oncology criteria
SPRYCEL (dasatinib) oncology criteria — selected examples
Prior therapy/resistance documentation required.
STELARA — Initial therapy criteria
STELARA — Initial therapy criteria
New starts only; prior therapy documentation required where specified.
STIVARGA — colorectal cancer
STIVARGA — colorectal cancer
Prerequisite therapy required.
SYMDEKO — combination therapy exclusion
SYMDEKO — combination therapy exclusion
Age restriction: 6 years or older.
TAFINLAR — BRAF mutation required
TAFINLAR — BRAF mutation required (indication‑specific)
Other tumor‑specific combination requirements exist (thyroid, LCH/ECD).
TAGRISSO — EGFR mutation-positive disease
TAGRISSO — EGFR mutation‑positive disease
Covers FDA‑approved and some medically‑accepted indications.
TERBINAFINE — Onychomycosis
TERBINAFINE — Onychomycosis
Prior authorization applies to cumulative therapy >90 days/year.
TERIPARATIDE — Initial and continuation criteria
TERIPARATIDE — Initial and continuation criteria
Continuation requires demonstration of ongoing high fracture risk and benefit (FRAX thresholds specified).
Testosterone products — diagnostic requirements
Testosterone products — diagnostic requirements
Continuation requires documented prior low morning total testosterone.
Tetrabenazine — initiation and continuation
Tetrabenazine — initiation and continuation
Initial authorization: 6 months; continuation requires benefit.
Continuation requires demonstrated benefit.
Quetiapine XR — Chorea and Tardive Dyskinesia
Quetiapine XR — Chorea and Tardive Dyskinesia
Continuation requires demonstrated benefit.
Continuation requires demonstrated benefit.
TIBSOVO (idasidenib) — AML and other indications
TIBSOVO (idasidenib) — AML and other indications
Required documentation of mutation and disease context.
TREPROSTINIL / UPTRAVI — Pulmonary arterial hypertension (WHO Group 1)
Covered when ALL of the following are met for new starts:
Applies to TREPROSTINIL and UPTRAVI PAH indications for new starts.
UCERIS (budesonide ER) — Induction for ulcerative colitis
Covered when the following are met:
Coverage duration: 2 months for induction.
TRAZIMERA — Selected solid tumors
TRAZIMERA — Selected solid tumors coverage conditions
Additional tumor‑specific combination requirements apply for hepatobiliary and endometrial cancer indications.
VENCLEXTA — Hematologic malignancies
VENCLEXTA — Hematologic malignancies
Indication‑specific requirements documented in product entry.
VENCLEXTA — Indications
VENCLEXTA — Indications
See product entries for per‑indication documentation requirements.
VENCLEXTA — Indication-specific criteria
VENCLEXTA — Indication‑specific criteria (examples)
Documentation per product required.
VOSEVI — Coverage criteria
VOSEVI — HCV coverage criteria
Exclusion: decompensated cirrhosis/CTP class B or C.
VOQUEZNA PAK — H. pylori
VOQUEZNA PAK — H. pylori
Coverage duration example: 14 days for H. pylori regimen.
VOWST — Recurrent CDI prevention
VOWST — prevention of recurrent CDI
Coverage duration: 1 month.
XOLAIR — Coverage criteria
XOLAIR — indication‑specific coverage
Continuation requires evidence of clinical benefit (reduced exacerbations/symptoms or reduced oral corticosteroid dose).
Continuation requires clinical benefit.
XIFAXAN — IBS-D and SIBO
XIFAXAN — IBS‑D and SIBO rules
Selected oncology drugs — coverage criteria
Selected oncology drugs — coverage criteria
See product entries for mutation testing and prior therapy requirements.
XYREM — Narcolepsy
XYREM — Narcolepsy coverage criteria
For cataplexy initial requests sleep‑lab confirmation required; continuation requires decreased daytime sleepiness or cataplexy episodes.
Continuation requires evidence of benefit (reduced EDS or cataplexy).
Psoriasis biologic criteria
Psoriasis biologic criteria — new starts
Applies to new starts for multiple biologic agents.
YUTREPIA coverage criteria
YUTREPIA coverage criteria (PAH/PH with ILD)
Prespecified for WHO Group 1 PAH or PH with ILD indications.
ZONISADE coverage criteria
ZONISADE adjunctive partial‑onset seizures criteria
Prerequisite therapy required.
ZYKADIA coverage criteria
ZYKADIA coverage criteria — ALK‑positive NSCLC
Prerequisite therapy required; prior authorization required.
ZEJULA coverage criteria
ZEJULA coverage criteria (selected example)
Applies to uterine leiomyosarcoma indication in excerpt.
This section summarizes the coverage criteria approach used across the HMSA prior authorization drug list. Coverage is contingent on meeting the specific clinical criteria listed for each product (for example, many oncology and specialty agents require documented diagnostic testing or mutation status and prior therapy history). Requests that do not meet the stated criteria may be denied. Providers must obtain prior authorization by calling HMSA at the number shown before dispensing any listed medication (see provider actions).
Some product entries include explicit off‑label exclusions or usage constraints. Examples in this excerpt include vaccine entries that limit coverage to patients who have not previously received the vaccine, oncology entries that require documented tumor mutation status and exclude certain off‑label disease settings, and drug–drug interaction exclusions (e.g., ergot/ergotamine or dihydroergotamine products contraindicated with potent CYP3A4 inhibitors). Where a product is routinely covered under Medicare Part A or B in the specified setting, coverage under Part D may be denied.
Coding, Thresholds and Numeric Criteria
Prior Authorization Actions and Required Documentation
Obtain prior authorization by phone (HMSA 24/7)
Prior authorization must be obtained before filling prescriptions for listed drugs. To request PA, call HMSA at 1 (855) 479-3659; the line is available 24 hours a day, 7 days a week (TTY/TDD 711). Coverage is contingent on HMSA determining the drug is prescribed according to the specified criteria.
Determine Medicare Part A/B vs Part D coverage
Some medications may be payable under Medicare Part A or Part B instead of Part D; coverage under Part D will be denied when coverage is available under Part A or Part B as the medication is prescribed and dispensed or administered for the individual.
Submit PA with drug‑specific clinical information
Prior authorization is required for many specialty, biologic, and other listed drugs; providers must submit the drug-specific required medical information, age limits, coverage duration, and prerequisite therapy documentation as specified for each product.
PA required for listed drug groups and indications
Prior authorization is required for the listed drug groups and indications; many groups require evidence of prior therapy trials, specialty prescriber or consultation, age limits, and supporting diagnostic testing as specified per drug group.
HRM PA: prescriber acknowledgement and geriatric safeguards (65+)
High‑Risk Medication (HRM) prior authorizations apply to older adults (typically age ≥65); prescribers must acknowledge that benefits outweigh risks and provide required documentation including trials of alternatives and cumulative therapy thresholds where specified.
- Prescriber attestation that benefit outweighs risks for patients ≥65
- Document trials/failures of specified non‑HRM alternatives when required
- PA triggers at cumulative duration thresholds (e.g., >30 or >90 days/year per group)
Specialty/oncology PA: provide diagnostics and prior‑therapy history
Specialty and oncology agents require prior authorization with indication-specific documentation; many entries expect diagnostic confirmation (e.g., mutation testing), prior‑therapy failure history, and sometimes specialist prescriber or consultation.
- Provide mutation or biomarker test results when required (e.g., BCR‑ABL, RET, BRAF, EGFR)
- Document prior lines of therapy, intolerances, or contraindications per product
Provide continuation documentation (demonstrate prior use/benefit)
Prior authorization for continuation or renewal often requires evidence of prior benefit or meeting continuation thresholds (examples include documented prior extended‑release opioid use ≥30 days or demonstrated clinical improvement on therapy).
- For ER opioids: request must be for a patient who has been receiving an ER opioid for at least 30 days
- Provide objective evidence of benefit for continuation (e.g., improved walking speed for DALFAMPRIDINE)
Use dose‑specific PA group for Lenvima
Lenvima dosing strengths are grouped by dose for PA; submit the request under the specific dosing variant listed (separate PA groups exist for multiple daily dose strengths).
- Select the PA group matching the requested Lenvima daily dose (4 mg, 8 mg, 10 mg, 12 mg, 14 mg, 18 mg, 20 mg, 24 mg).
MAVYRET PA: HCV RNA, genotype, cirrhosis and regimen details
MAVYRET requires prior authorization for HCV; providers must document HCV RNA prior to treatment and submit planned regimen, genotype, cirrhosis status, HIV coinfection, resistance‑associated substitutions where applicable, transplant status, and follow current AASLD‑IDSA guidance for durations.
- Confirm HCV RNA present in serum before initiating therapy
- Provide genotype, cirrhosis status (CTP class), prior treatment history, HIV coinfection status, and transplant status
Coverage contingent on meeting PA criteria — denial risk
Prior authorization is required for the listed drugs; HMSA provides coverage only after confirming the drug is prescribed according to the stated criteria — requests that do not meet PA criteria may be denied.
STELARA PA: document psoriasis extent or prior therapy for new starts
STELARA requires prior authorization for all FDA‑approved indications; for new‑start moderate to severe plaque psoriasis, document BSA or crucial body‑area involvement or prior therapy failure/intolerance per the listed new‑start criteria.
- Document crucial body areas affected or BSA ≥10% (or ≥3% with prior therapy failure/intolerance)
- Provide prior phototherapy or systemic agent trial history when applicable
STIVARGA PA: colorectal cancer after Lonsurf failure/intolerance
STIVARGA (regorafenib) requires prior authorization for colorectal cancer: document advanced/metastatic disease and prior inadequate response, intolerance, or contraindication to trifluridine/tipiracil (Lonsurf).
- Provide treatment history showing failure/intolerance/contraindication to trifluridine/tipiracil
- Confirm disease is advanced or metastatic
VENCLEXTA PA: submit indication‑specific AML/myeloma documentation
VENCLEXTA prior authorization requires indication‑specific documentation; for AML and other hematologic indications submit the diagnosis details and evidence that the patient meets the listed per‑indication criteria (e.g., age/comorbidity constraints, relapsed/refractory status, t(11;14) for certain myeloma uses).
- For AML: document newly‑diagnosed status with age ≥75 or comorbidities precluding intensive induction OR relapsed/refractory/post‑induction scenarios as specified
- For multiple myeloma: document t(11;14) translocation and combination regimen
VOQUEZNA PAK PA: document H. pylori susceptibility or local epidemiology
VOQUEZNA PAK requires prior authorization for H. pylori treatment; document that the infection is proven or strongly suspected to be caused by susceptible bacteria based on culture/susceptibility or local epidemiology and susceptibility patterns.
- Provide culture and susceptibility data when available or reference local epidemiology supporting use
PA for selected drugs (e.g., XIFAXAN, XOLAIR): submit indication‑specific data
Selected drugs such as XIFAXAN and XOLAIR require prior authorization with indication‑specific required information; submit the criteria‑specific documentation (e.g., IBS‑D/SIBO treatment history for XIFAXAN; allergen testing, baseline IgE, and controller therapy failure for XOLAIR).
- XIFAXAN: document recurrence/diagnostic test results or prior course history for IBS‑D/SIBO
- XOLAIR: provide positive allergen test or baseline IgE and inadequate control on specified controller therapy for asthma
Denial risk if PA criteria unmet
If PA criteria are not met, coverage may be denied — HMSA will only provide coverage after determining the drug is prescribed according to the specified criteria.
DHE NASAL contraindication with potent CYP3A4 inhibitors (denial risk)
DHE NASAL coverage will be denied if used concomitantly with potent CYP3A4 inhibitors (examples: ritonavir, nelfinavir, indinavir, erythromycin, clarithromycin); do not submit PA requests that include such concomitant use.
- Ensure therapy is not co‑prescribed with potent CYP3A4 inhibitors before requesting PA
Part D denial risk when Part A/B coverage applies
If a drug is payable under Medicare Part A or Part B in the prescribed setting, Part D coverage will be denied; providers should confirm the correct Medicare payment part before submitting PA.
Confirm Part A/B applicability before submitting Part D PA
If a medication is appropriately covered under Medicare Part A or Part B as prescribed and administered for the individual, coverage under Part D will be denied; verify site‑of‑care and payer part applicability when submitting PA for Medicare beneficiaries.
PAH agents: submit RHC hemodynamics for new starts
For PAH agents (new starts) including TREPROSTINIL and YUTREPIA, prior authorization requires right heart catheterization confirmation and pretreatment hemodynamics meeting: mean pulmonary arterial pressure >20 mmHg, pulmonary capillary wedge pressure ≤15 mmHg, and pulmonary vascular resistance >2 Wood units.
- Attach right heart catheterization hemodynamic values (mPAP, PCWP, PVR) to the PA request
PAH diagnostic thresholds required for PA (RHC values)
PAH confirmation is defined by right heart catheterization showing mean pulmonary arterial pressure >20 mmHg, pulmonary capillary wedge pressure ≤15 mmHg, and pulmonary vascular resistance >2 Wood units; lack of these documented values for new starts may trigger denial.
- Provide pretreatment mPAP, PCWP, and PVR measured by right heart catheterization
Initial Authorization Requirements
Renewal and Continuation Requirements
Required Prior Trials and Step Therapy
| Requirement | Examples / Notes |
|---|---|
| Prior trial of specified agents or classes required | Examples: Acitretin — inadequate response/intolerance/contraindication to methotrexate or cyclosporine before approval; Auvelity (MDD) — inadequate response/intolerance or contraindication to TWO of SNRIs, SSRIs, mirtazapine, bupropion. |
| Documentation of contraindication or intolerance accepted instead of trial | Many entries permit documentation of contraindication or intolerance in lieu of trials for initial approval of listed drugs (see biologics and specialty agents). |
| Severity exceptions may allow first‑line biologic without prior trials | For moderate–severe plaque psoriasis severe disease (≥10% BSA) or crucial body area involvement may justify biologic as first‑line without prior phototherapy/systemic agent trials (BIMZELX example). |
| Requirement | Documentation Required |
|---|---|
| Prior failure, intolerance, or contraindication to specified non‑biologic therapies required for new biologic starts | Example: BIMZELX (psoriasis) — prior inadequate response/intolerance to phototherapy or methotrexate/cyclosporine/acitretin required for ≥3% BSA cases; otherwise crucial area or ≥10% BSA can justify biologic first‑line. |
| Document clinical justification if biologic is used first‑line due to severity | Policy permits biologic-first when disease severity (e.g., ≥10% BSA or crucial body areas) warrants; document extent of disease and rationale. |
| Record specific prior agents tried and outcomes (response/intolerance) or list contraindications | For rheumatology biologics new starts typically require methotrexate failure/intolerance or prior biologic/targeted DMARD failure — document agents and reasons. |
| Agent / Group | Prior therapy documentation required |
|---|---|
| Antifungals (e.g., CRESEMBA) | Document inadequate response/intolerance/contraindication to listed alternatives or prior azole/antifungal therapy where specified. |
| CGRP antagonists (EMGALITY) — cluster headache | Document inadequate response/intolerance/contraindication to a triptan 5‑HT1 receptor agonist for episodic cluster headache; continuation requires response duration noted. |
| Psychiatric/CNS agents (selected) | Document trials and failures of specified generics/alternatives (e.g., for MDD agents, two classes; for certain antipsychotics, list of generics tried). |
| Requirement | Specific generic/alternative agents referenced |
|---|---|
| Trial and failure/intolerance to a generic anticonvulsant before branded agent approval | Examples: For partial‑onset seizures the patient must have inadequate response/intolerance to a generic anticonvulsant and to listed alternatives (Aptiom, Xcopri, Spritam) where applicable. |
| Trial of listed generic antidepressants required for some MDD/ anxiety agents | Examples: For MDD/related agents, documentation of inadequate response/intolerance to two of SNRIs, SSRIs, mirtazapine, or bupropion is required (AUVELITY, EMSAM). |
| Non‑HRM alternatives required prior to HRM agents in older adults | HRM groups require trials of non‑HRM alternatives (e.g., for insomnia: doxepin 3/6 mg or ramelteon) unless contraindicated; document trials or contraindications. |
| Step requirement | Example — alternatives and outcomes to document |
|---|---|
| Rheumatologic alternatives before biologic/targeted agents | Document trials of methotrexate, cyclosporine, acitretin or contraindications — e.g., STELARA, HUMIRA, and other biologics require methotrexate or documented intolerance/failure when applicable. |
| Phototherapy or systemic agents before psoriasis biologics (when BSA <10% / 3% threshold cases) | For ≥3% BSA cases initiating biologic, document inadequate response/intolerance to phototherapy (UVB/PUVA) or methotrexate/cyclosporine/acitretin, unless crucial body area involvement or ≥10% BSA present. |
| NSAID trial for axial spondyloarthritis/AS before biologic | For ankylosing spondylitis/axial SpA new starts: document inadequate response/intolerance to an NSAID or contraindication to NSAIDs prior to biologic (BIMZELX example). |
| HRM group | Required alternative trials / number of alternatives |
|---|---|
| Anxiety HRM agents (e.g., hydroxyzine) | Require trial of two alternatives (buspirone, duloxetine, escitalopram, sertraline, venlafaxine XR) with documentation of inadequate response/intolerance OR acute anxiety exception; prescriber must acknowledge benefit outweighs risks. |
| Insomnia HRM agents (e.g., meclizine entry context) | Require trial of non‑HRM alternatives (doxepin 3/6 mg or ramelteon) unless contraindicated, and documentation if two or more additional CNS‑active meds are used; cumulative duration thresholds apply. |
| Rhinitis HRM antihistamines | Require trials of two non‑HRM alternatives (levocetirizine, azelastine nasal, fluticasone nasal, flunisolide nasal) with inadequate response/intolerance documented before HRM approval. |
| Specialty/oncology agent | Prior therapy / contraindication documentation required |
|---|---|
| TKIs for CML/Ph+ disease (e.g., BOSULIF) | Document Philadelphia chromosome/BCR‑ABL confirmation and prior resistance/intolerance to imatinib, dasatinib, or nilotinib as specified; mutation testing (e.g., T315I) status required where indicated. |
| Kinase inhibitors for GIST or other tumors (e.g., ICLUSIG, QINLOCK) | Document prior kinase inhibitor therapy failures (number and agents vary by product) or intolerance; provide mutation/biomarker testing where required. |
| Targeted agents requiring molecular confirmation (e.g., PI3K/PIK3CA, IDH1) | Document tumor molecular testing (e.g., PIK3CA for alpelisib/Itovebi; IDH1 for TIBSOVO) and prior lines of therapy or intolerance as specified. |
| Product / New start requirement | Required prior medications to document |
|---|---|
| Kineret (anakinra) — RA / SJIA new starts | New starts require failure/intolerance or contraindication to two specified RA agents (biologic/small‑molecule products); document agents tried and outcomes. |
| IVIG — specific indications | For B‑cell CLL, BMT/HSCT, pediatric HIV, dermatomyositis/polymyositis, PRCA: document IgG thresholds or history of recurrent infections and prior standard therapies as applicable per indication. |
| Deutetrabenazine prerequisite for tetrabenazine/quetiapine XR contexts | Quetiapine XR and tetrabenazine entries require documentation of inadequate response/intolerance to deutetrabenazine before approval for chorea or tardive dyskinesia new starts. |
| Scenario | Required prior medication examples to document |
|---|---|
| IVIG initiation for B‑cell CLL | Document serum IgG <500 mg/dL or history of recurrent bacterial infections and prior standard therapy failure where relevant. |
| Kineret for RA new starts | Document intolerance or inadequate response to two specified biologic/synthetic DMARDs (e.g., adalimumab, etanercept, tofacitinib equivalents) per policy. |
| ICATIBANT for HAE acute attacks | Document laboratory confirmation of HAE type (C1 inhibitor deficiency/dysfunction) or genetic/family history plus prior trials as required. |
| Group / Flag | Implication for approval |
|---|---|
| ’Prerequisite Therapy Required = Yes’ listed for some products | Examples include LYNPARZA and several oncology/specialty agents — when flagged, prior therapy trials or documented intolerance/contraindication must be provided per product entry. |
| Biosimilar substitution/intolerance considerations | Some biosimilars (e.g., ONTRUZANT/OGIVRI) require documentation of prior intolerance to another biosimilar (e.g., Trazimera) not attributed to active ingredient before switching; document prior AE and attribution per PI. |
| Device or regimen prerequisites | For devices (e.g., OMNIPOD) and combination regimens, document prior conservative management and specific criteria (e.g., insulin MDI with frequent self‑testing) as listed. |
Quantity and Duration Limits
Key Definitions and Diagnostic Confirmations
Policy Background and Scope
Background: This policy document compiles drug‑specific prior authorization requirements that tie coverage to clinical diagnoses, laboratory or genetic testing, hemodynamic measurements, age limits, prior‑therapy trials, and other required supporting information. Many entries require specialty prescriber involvement or documentation showing the patient meets indication‑specific thresholds (for example, molecular testing for targeted oncology agents or right‑heart catheterization hemodynamics for pulmonary arterial hypertension).
The table entries are intended to guide prescribers and reviewers: when a drug’s listed criteria and any required documentation are satisfied, the plan may provide coverage for the drug; when criteria are not met, the request may be denied. Providers should call HMSA to request prior authorization and submit the indicated supporting medical information (diagnostic test results, mutation reports, prior treatment history, lab values, etc.) as specified for each product.
Policy Revision History
Initial publication of the HMSA prior authorization drug criteria document listing drugs that require prior authorization and their coverage criteria.
Updated multiple drug entries with clarified required medical information and hemodynamic thresholds for PAH new starts; added device and vaccine-specific notes (e.g., RSV vaccines coverage condition).
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