CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior Authorization Request Form — H.P. Acthar Gel / Purified Cortrophin Gel

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This document is a prior authorization request form administered by CVS Caremark for HMSA members; it governs how providers submit authorization requests and clinical information for certain medications (e.g., H.P. Acthar Gel) to determine coverage.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request Form — H.P. Acthar Gel / Purified Cortrophin Gel

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form to CVS Caremark at 1-866-237-5512 with diagnosis, ICD-10 code, drug requested, administration/dispensing site, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1primary listed medication (H.P. Acthar Gel)

2listed drug options

1-866-237-5512fax number to submit form

1-808-254-4414phone for prior authorization questions

CaremarkConnectSpecialty Customer Care

Prior Authorization Coverage Criteria

Prior authorization question set for Acthar/Cortrophin Gel

Questions the prescriber must answer to support coverage consideration for H.P. Acthar Gel or Purified Cortrophin Gel:

Indicate dispensing site (office, outpatient hospital, ambulatory surgical, inpatient hospital, pharmacy, etc.)

Indicate administration site (ambulatory surgical, home, inpatient hospital, office, outpatient hospital, pharmacy, etc.)

Provide patient diagnosis (selectable option: Infantile spasms or other) and supply the ICD-10 code

Select the drug requested: H.P. Acthar Gel or Purified Cortrophin Gel

State whether H.P. Acthar Gel will be used in combination with Purified Cortrophin Gel (Yes/No)

Indicate whether the request is a new start or a continuation of therapy

If continuation of therapy, attest whether the patient has shown substantial clinical benefit from therapy (Yes/No)

If initiating H.P. Acthar Gel in a patient < 2 years old, indicate yes or no

Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines

Requested Diagnosis and Coding

Requested diagnosis codingICD-10

Form requests the ICD-10 code for the patient's diagnosis; specific codes are not provided in the document.

Submission Instructions and Provider Requirements

Prior Authorization

Prior Authorization Submission

Fax the completed prior authorization form to CVS Caremark toll-free at 1-866-237-5512. Include the patient diagnosis and ICD-10 code, the specific drug requested (H.P. Acthar Gel or Purified Cortrophin Gel), drug request details, and supporting clinical documentation. For questions about prior authorization determinations, contact CVS Caremark at 1-808-254-4414. For specialty customer care (eligibility, copay, or medication delivery), contact CaremarkConnect® at 1-800-237-2767.

Fax: 1-866-237-5512
CVS Caremark Prior Auth questions: 1-808-254-4414
CaremarkConnect (Specialty Customer Care): 1-800-237-2767
Include: diagnosis, ICD-10 code, drug requested, supporting clinical information

Documentation Required

Therapy Status and Age Criteria

Answer the form's therapy-status and age criteria questions exactly as presented: indicate whether this is a new start or a continuation of therapy; if initiating H.P. Acthar Gel, state whether the patient is less than 2 years of age; and for continuation requests, indicate whether the patient has shown substantial clinical benefit from therapy. Ensure the prescriber or authorized signer attests that documentation supporting these responses is available for review.

Therapy status: New start or Continuation (if continuation, skip to benefit question)
Age criterion (for H.P. Acthar Gel initiation): Is patient < 2 years? Yes / No
Continuation therapy: Has the patient shown substantial clinical benefit? Yes / No
Attestation: Prescriber signature and date required; documentation must be available upon request

Note

Approval Limits

Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and evidence-based practice guidelines.

Key Terms and Definitions

inv-06: prior authorization — definition

DefinitionPrior authorization is a requirement by the benefit plan for certain medications to be approved before they are covered.

PurposeEnsures the plan has necessary clinical and administrative information to make an appropriate coverage determination for the requested medication.

Submission requirementProviders must complete and fax the prior authorization form to CVS Caremark at 1-866-237-5512.

Support contactFor prior authorization questions contact CVS Caremark at 1-808-254-4414; for Specialty Customer Care contact CaremarkConnect 1-800-237-2767.

ScopeApplies to certain specialty medications administered under the patient's benefit plan (example: H.P. Acthar Gel / Purified Cortrophin Gel).

inv-07: substantial clinical benefit — form note

Form promptThe prior authorization form asks whether the patient has shown substantial clinical benefit from therapy (Yes/No).

Definition statusNo formal definition of 'substantial clinical benefit' is provided in the form or accompanying document.

Use in workflowA positive attestation of substantial clinical benefit is requested for continuation of therapy (question appears when 'Continuation' is selected).

Documentation expectationPrescriber attests that supporting documentation is available for review if requested by CVS Caremark or the benefit plan sponsor.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request Form — H.P. Acthar Gel / Purified Cortrophin Gel

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form to CVS Caremark at 1-866-237-5512 with diagnosis, ICD-10 code, drug requested, administration/dispensing site, and prescriber signature.

SourceLink

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