Prior authorization request form for long-acting CSF biologics
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This document is a prior authorization (PA) request form administered by CVS Caremark for certain long-acting colony-stimulating factor (CSF) products for HMSA members; it governs how clinicians request PA and the exception criteria needed for coverage determinations.
No material clinical or coverage changes in this revision.
Coverage & Exception Decision Flow
Exception-based coverage decision flow
Form directs selection of product and follows a decision flow for coverage/PA based on product preference and indication.
Preferred products (No PA required)
- Fulphila — No further action is needed. No PA is required.
- Neulasta (including Onpro) — No further action is needed. No PA is required.
- Nyvepria — No further action is needed. No PA is required.
Non-preferred products (PA required; continue to Exception Criteria Questions)
- Fylnetra — Continue to Exception Criteria Questions.
- Rolvedon — Continue to Exception Criteria Questions.
- Stimufend — Continue to Exception Criteria Questions.
- Udenyca — Continue to Exception Criteria Questions.
- Udenyca Onbody — Continue to Exception Criteria Questions.
- Ziextenzo — Continue to Exception Criteria Questions.
Exception Criteria decision flow (for non-preferred products)
- Question 1: Can the patient's treatment be switched to a preferred product? If Yes → No further action; No PA required for preferred products.
- If Question 1 = No → Question 2: Is the product being requested for neutropenia associated with myelosuppressive anti-cancer therapy? If No → No further questions (not indicated).
- If Question 2 = Yes → Question 3: Has the patient failed treatment with all preferred products due to an intolerable adverse event? If Yes → Attach supporting chart note(s) and continue to Question 4; if No → continue to Question 4.
- Question 4: Was the intolerable adverse event an expected adverse event attributed to the active ingredient as described in the prescribing information (i.e., known adverse reaction for both the brand and biosimilar)? If No → Attach supporting chart note(s). Responses conclude the exception assessment and will be reviewed for possible approval.
Diagnosis, Dosing, and Coding Notes
| Field on form asks prescriber to provide ICD-10 code for diagnosis |
Submission, Documentation, and When to Request PA
Submission and contact instructions
Fax completed prior authorization form to CVS Caremark toll-free at 1-866-237-5512. For questions regarding the prior authorization contact CVS Caremark at 1-808-254-4414. For specialty or patient eligibility/copay/delivery questions contact CaremarkConnect at 1-800-237-2767.
- Fax number for submission: 1-866-237-5512
- Prior authorization questions: 1-808-254-4414
- Specialty/eligibility/copay/delivery inquiries: CaremarkConnect 1-800-237-2767
When prior authorization is required
Indicate which product is being requested on the form and complete the exception criteria questions when requesting a non-preferred product; if a preferred product (Fulphila, Neulasta including Onpro, or Nyvepria) is selected, no prior authorization is required.
- Select the product on the form (Fulphila, Fylnetra, Neulasta, Neulasta Onpro, Nyvepria, Rolvedon, Stimufend, Udenyca, Udenyca Onbody, Ziextenzo).
- If Fulphila, Neulasta (including Onpro), or Nyvepria → No PA required.
- If a non-preferred product is selected → complete the Exception Criteria Questions on the form.
Documentation required for non-preferred product exceptions
When requesting a non-preferred product, attest on the form and attach supporting chart notes if the request cites failure of, or an intolerable adverse event to, preferred products.
- If patient has failed preferred products due to an intolerable adverse event → attach supporting chart note(s) as instructed on the form.
- Prescriber must sign the attestation that documentation is available for review by CVS Caremark or the benefit plan sponsor.
Preferred Products & Exception Criteria
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