CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSA Medicare Advantage – Prior Authorization Request (CVS Caremark)

This document governs the prior authorization request process administered by CVS Caremark for HMSA Medicare Advantage members, specifying required clinical and demographic information clinicians must provide to determine drug coverage.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request form for prescription medications (CVS Caremark administered)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with accurate diagnosis and required clinical documentation to CVS Caremark.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number to submit PA

1phone number for CVS Caremark PA inquiries

2preferred products named

365prior treatment lookback (days)

Coverage and Exception Criteria

Exception and Clinical Criteria

Exception criteria and clinical questions used to evaluate requests for non‑preferred or biologic products.

ALL of the following

Preferred product switch
- Can the patient's treatment be switched to a preferred product (Riabni or Truxima)? If yes, obtain the form for the preferred product and submit the corresponding prior authorization.
Prior exposure
- Has the patient received treatment with the requested product in the past 365 days? If yes, skip to Criteria Questions; if no, continue to intolerance assessment.
Intolerance to preferred products

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request form for prescription medications (CVS Caremark administered)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form with accurate diagnosis and required clinical documentation to CVS Caremark.

SourceLink

On This Page

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Clinical criteria questions

List or describe all agents in the oncology regimen and indicate single vs multiple agents.
Provide the patient's diagnosis and ICD‑10 code. Action required: attach relevant supporting data of the patient's diagnosis.
Is the requested medication/regimen prescribed for an FDA‑approved indication or an indication supported by NCCN with a I or IIA recommendation? (Yes/No)
Is there a contraindication to the requested medication(s) as listed in the prescribing information? (Yes/No)
Was the single agent or entire drug regimen previously authorized by HMSA/CVS for this member? (Yes / No / Unknown). If No or Unknown, no further questions.
Is there evidence the patient is benefitting from treatment (e.g., positive clinical response, lack of disease progression)? Action required: attach current clinical documentation (office visit notes, applicable studies). (Yes/No)

Submission, Documentation, and Provider Instructions

Prior Authorization

Prior Authorization Required — Submission & Documentation

Complete and fax the prior authorization form with required clinical documentation to CVS Caremark for HMSA Medicare Advantage members. Fax toll-free to 1-866-237-5512. Include the most accurate diagnosis and supporting chart notes, dosing information, and any documentation of prior therapy or adverse events as applicable. Approvals may be subject to dosing limits per FDA labeling, accepted compendia, and evidence-based guidelines.

Fax: 1-866-237-5512 (toll-free)
Include: accurate diagnosis, chart notes, prior therapy dates, adverse event documentation, dosing information
Specialty questions: CVS Caremark 1-808-254-4414
Patient eligibility/drug copay/medication delivery: CaremarkConnect 1-800-237-2767

Step Therapy

Exception & Step Therapy Procedures for Preferred Products

If preferred biosimilars (Riabni, Truxima) are alternatives for the member's plan, follow exception and step procedures below. Indicate on the form whether the patient can be switched to a preferred product. If yes, obtain and submit the PA form for the preferred product. If no, complete the remainder of the exception questions and attach supporting documentation.

Preferred products for HMSA: Riabni and Truxima
If patient CAN be switched: check 'Yes' and submit PA for preferred product
If patient received the requested product in the past 365 days: check 'Yes' and proceed to criteria
If patient has NOT received the product in past 365 days: continue to Question C
If patient has documented intolerable adverse events to BOTH Riabni and Truxima: check 'Yes' and provide chart notes
If intolerable adverse event was NOT an expected adverse event attributable to the active ingredient per prescribing information: attach supporting chart notes

Note

Contact Information & Fax Opt-Out Instructions

Contact CVS Caremark for prior authorization questions or specialty customer care using the numbers below. Recipients of this fax may opt-out of receiving telemarketing fax transmissions from CVS Caremark by calling 877-265-2711 (24/7) or emailing do_not_call@cvscaremark.com. Opt-out requests must identify the fax number and will be honored within 30 days; an opt-out is only valid if the requester does not subsequently give express permission to receive facsimile advertisements at that number.

PA questions: CVS Caremark 1-808-254-4414
Specialty Customer Care / CaremarkConnect: 1-800-237-2767
Opt-out phone: 877-265-2711 (24/7)
Opt-out email: do_not_call@cvscaremark.com
Opt-out requirements: must identify the number; honored within 30 days

OpenPayer

HMSA Medicare Advantage – Prior Authorization Request (CVS Caremark)

Coverage and Exception Criteria

Diagnosis Coding and Lookback

Submission, Documentation, and Provider Instructions

Key Definitions