Hawaii Medical Service Association (HMSA) Coverage Criteria
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Latest Hawaii Medical Service Association (HMSA) coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Adbry (tralokinumab-ldrm) Coverage CriteriaThis policy governs HMSA commercial coverage and prior authorization for Adbry in members aged 12 years and older with moderate-to-severe atopic dermatitis. It defines clinical criteria, documentation, prescriber qualifications, continuation requirements, and authorization durations.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Dupixent (dupilumab) Coverage and Prior AuthorizationThis policy governs HMSA coverage and authorization requirements for Dupixent (dupilumab) for specified FDA-approved and compendial indications. It applies to HMO and PPO members and requires indication-specific clinical criteria, documentation, prescriber qualifications, and continuation requirements.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Nemluvio (nemolizumab-ilto) Coverage CriteriaThis policy governs prior authorization and reauthorization for Nemluvio for adult prurigo nodularis and moderate-to-severe atopic dermatitis in members aged 12 years and older. It applies to HMSA QUEST members and requires clinical documentation, specialty prescribing or consultation, and satisfaction of indication-specific criteria.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Nemluvio (nemolizumab-ilto) Coverage CriteriaThis policy governs HMSA prior authorization and coverage criteria for Nemluvio for adult prurigo nodularis and moderate-to-severe atopic dermatitis in members age 12 and older. It applies to HMO and PPO members and requires documentation, qualifying prior therapy or clinical circumstances, and specialty prescribing.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-26Bimzelx (bimekizumab-bkzx) Coverage CriteriaHMSA coverage and prior authorization criteria for Bimzelx in adults with specified inflammatory dermatologic and rheumatologic conditions.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-26Vimizim (elosulfase alfa) Coverage CriteriaThis policy governs HMSA Medicare Advantage coverage and precertification for Vimizim (elosulfase alfa) used to treat Mucopolysaccharidosis type IVA (MPS IVA, Morquio A syndrome), including initial authorization and reauthorization.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Flolan, Veletri, and Epoprostenol Injection Coverage CriteriaThis policy governs prior authorization and coverage of epoprostenol products for pulmonary arterial hypertension. It applies to eligible HMSA HMO, PPO, and QUEST members when the clinical and documentation criteria are met.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Actemra, Avtozma, Tofidence, and Tyenne (tocilizumab) Coverage CriteriaOutpatient coverage and precertification for four tocilizumab products in Medicare Advantage members for specified FDA-approved and compendial indications when applicable criteria are met; hospitalized COVID-19 treatment is managed under the inpatient benefit.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Liquid BiopsyCoverage criteria for liquid biopsy testing, including cfDNA/ctDNA, circulating tumor cell, urinary, cerebrospinal fluid, and other tumor-derived biomarker testing for HMSA members.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-19Cinryze (C1 esterase inhibitor [human])This policy governs HMSA Medicare Advantage coverage and prior authorization for Cinryze to prevent hereditary angioedema attacks in adults, adolescents, and children age 6 years and older who meet the policy’s diagnostic and clinical criteria.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01LeuprolideThis policy governs HMSA prior authorization and coverage criteria for leuprolide products, including Lupron Depot, Lupron Depot-PED, generic leuprolide acetate, and Fensolvi. It applies to HMO, PPO, and QUEST members and addresses FDA-approved and compendial indications, initial approval, continuation, documentation, and exclusions.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-19Evenity (romosozumab-aqqg) coverage for postmenopausal osteoporosisThis policy governs HMSA prior authorization and coverage for Evenity in HMO, PPO, and QUEST members with postmenopausal osteoporosis. Coverage requires applicable clinical criteria, supporting documentation, and adherence to the 12-month dosing limitation.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-19Gonal-f (follitropin alfa) Coverage CriteriaThis policy governs HMSA coverage and precertification requirements for Gonal-f in fertility treatment for HMO and PPO members when eligible indications, preferred-product exception documentation, and related infertility benefit requirements are satisfied.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-19SKYRIZI (risankizumab-rzaa) Coverage and Prior AuthorizationThis policy governs HMSA coverage and authorization of Skyrizi (risankizumab-rzaa) for adults with plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis across HMO, PPO, and QUEST lines of business, with indication-specific clinical criteria and required precertification.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-19Soliris, Bkemv, and Epysqli (eculizumab products) Coverage and Prior AuthorizationThis policy governs HMSA coverage and prior authorization requirements for Soliris, Bkemv, and Epysqli for eligible members with specified complement-mediated and antibody-positive neurologic conditions across HMO, PPO, and QUEST lines of business.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-21Botulinum Toxin Product ExceptionsThis policy establishes preferred botulinum toxin products for HMSA Medicare Advantage members and prior authorization exception criteria for coverage of nonpreferred products.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-21Nplate (romiplostim) Coverage CriteriaThis policy governs Medicare Advantage coverage and prior authorization requirements for Nplate (romiplostim) for immune thrombocytopenia, hematopoietic syndrome of acute radiation syndrome, myelodysplastic syndromes, and chemotherapy-induced thrombocytopenia. Coverage is subject to indication-specific clinical criteria, documentation, authorization durations, and continuation requirements.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-27SILIQ (brodalumab) Coverage Criteria for Plaque PsoriasisThis policy governs HMSA coverage and prior authorization for SILIQ (brodalumab) in adult members with moderate to severe plaque psoriasis. Coverage requires applicable clinical criteria, prescriber requirements, safety screening, and absence of exclusions.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-24Home Health Care - QUEST IntegrationThis policy governs coverage, medical necessity, precertification, documentation, limitations, and applicable billing codes for intermittent skilled home health services provided by licensed home health agencies to QUEST Integration members in their residences.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-24Small Bowel/Liver and Multivisceral TransplantCoverage and precertification for small bowel and liver transplantation, multivisceral transplantation, and retransplantation in pediatric and adult individuals with intestinal failure and related liver failure for inpatient services under HMSA HMO and PPO plans.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01LEQEMBI (lecanemab-irmb) Coverage CriteriaThis policy governs HMSA coverage and prior authorization for Leqembi in members with Alzheimer's disease, including initial and continuation therapy requirements. It applies to HMO, PPO, and QUEST lines of business and requires clinical documentation, specialist prescribing or consultation, and monitoring for amyloid-related imaging abnormalities.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Botulinum Toxins — Coverage Criteria (prior authorization to CVS Caremark Specialty Programs)Defines clinical and administrative requirements for prior authorization and medical necessity of botulinum toxin products (e.g., Botox, Dysport, Xeomin, Myobloc, Daxxify) for a range of neurologic and other indications under the payer's prescription/specialty benefit; applies to providers submitting authorization to CVS Caremark for HMSA members.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-05-01Global Medicare Advantage Medical Prior Authorization Request (Specialty Drugs Coverage Criteria)Form and criteria used by CVS Caremark on behalf of HMSA to collect information and authorize coverage for certain specialty medications for Medicare Advantage members; affects prescribers seeking drug coverage under the medical or pharmacy benefit.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-01Lupkynis (voclosporin) Coverage Criteria for Active Lupus NephritisThis policy governs HMSA prior authorization and coverage of Lupkynis in combination with background immunosuppressive therapy for adults with active lupus nephritis. It establishes documentation, initial approval, continuation, and exclusion requirements.All Hawaii Medical Service Association (HMSA) updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-01Valchlor (mechlorethamine gel) Coverage CriteriaThis policy governs HMSA coverage and prior authorization for Valchlor topical gel for specified cutaneous lymphomas and histiocytic neoplasms when applicable approval criteria are met and no exclusions apply.All Hawaii Medical Service Association (HMSA) updates
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Tool Description
Search Hawaii Medical Service Association (HMSA) coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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