CurrentHawaii Medical Service Association (HMSA)Policy N/A

Trastuzumab and biosimilars prior authorization request form

This document is a prior authorization request form and criteria checklist used by HMSA Medicare Advantage (administered by CVS Caremark) to evaluate coverage for trastuzumab (Herceptin) and specified biosimilars; it affects prescribing clinicians and pharmacy/specialty benefit administrators for affected members.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyTrastuzumab and biosimilars prior authorization request form

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective Date

Next Review Date

Key ActionComplete and fax the prior authorization form with accurate diagnosis and supporting documentation to CVS Caremark at 1-866-237-5512.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8listed product names

2preferred biosimilars

365prior receipt lookback

3Caremark contact numbers

Authorization Decision Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior authorization decision nodes

Authorization requires completion of the exception and criteria questions with supporting documentation where indicated.

Completion of the Exception Criteria Questions and Criteria Questions is required; attach supporting chart notes or clinical documentation where the form requests 'ACTION REQUIRED'.

Product requested

Requested product is Kanjinti or Trazimera (preferred)
ALL of the following
- Assess whether the patient can be switched to a preferred product (Kanjinti or Trazimera). If switch possible, request may be denied; if not, continue evaluation.

Prior use lookback: Has the patient received treatment with the requested product in the past 365 days? If Yes, skip to Criteria Questions; if No, continue through the form.

Intolerance to preferred products: Does the patient have a documented intolerable adverse event to both preferred products (Kanjinti and Trazimera)? ACTION REQUIRED: If Yes, attach supporting chart note(s).

Adverse event attribution: If an intolerable adverse event is documented, indicate whether it was an expected adverse event attributed to the active ingredient as described in the prescribing information. ACTION REQUIRED: If 'No', attach supporting chart note(s).

Indication and contraindication checks: Criteria Questions must be answered: provide ICD-10 diagnosis code(s); list agents in the oncology regimen; confirm whether use is for an FDA‑approved indication or an NCCN I/IIA supported indication; and indicate any contraindications per prescribing information. Attach relevant supportive data of diagnosis and prescribing information as requested.

Prior authorization history and benefit evidence: Indicate whether the regimen was previously authorized by HMSA/CVS for this member. Provide evidence of benefit (e.g., positive clinical response or lack of disease progression). ACTION REQUIRED: Attach current clinical documentation (office notes, studies) to support ongoing benefit when asked.

Submission, Documentation, and Product Selection

Prior Authorization

Prior authorization submission and contact information

Complete and fax the prior authorization form with an accurate diagnosis and all required supporting documentation to CVS Caremark. Fax: 1-866-237-5512 (toll-free). For prior authorization questions contact CVS Caremark at 1-808-254-4414. For Specialty Customer Care (eligibility, copay, delivery) contact CaremarkConnect® at 1-800-237-2767.

Fax prior authorization form and supporting documentation to 1-866-237-5512
Prior authorization questions: 1-808-254-4414
Specialty Customer Care (eligibility/copay/delivery): CaremarkConnect® 1-800-237-2767

Documentation Required

Clinical criteria and documentation requirements

Answer the exception and criteria questions on the form and attach supporting documentation where indicated. Provide the ICD-10 code, description of the oncology regimen (single or multiple agents), documentation of diagnosis, prior authorization history, and current clinical documentation demonstrating benefit when requesting continuation therapy. If requesting an exception due to intolerance to preferred products, attach supporting chart notes and specify whether the adverse event is an expected reaction attributed to the active ingredient per prescribing information.

Provide ICD-10 code and supportive diagnostic data
List all agents in the oncology regimen; indicate single vs multiple agents
Indicate if medication/regimen is for an FDA-approved indication or NCCN I / IIA-supported indication
Document contraindications to the requested medication(s), if present
If continuation request, attach clinical documentation showing benefit (e.g., office notes, studies)
If claiming intolerance to preferred products, attach chart notes and specify if adverse event is an expected reaction per prescribing information

Step Therapy

Preferred product / step requirement

Kanjinti and Trazimera are the preferred biosimilar products. Requests for non-preferred products (Herceptin, Herceptin Hylecta, Herzuma, Ogivri, Ontruzant) require justification that the patient cannot be switched to a preferred product or documentation of intolerable adverse events to both preferred products. If the patient has received the requested product within the past 365 days, indicate prior receipt on the form.

Preferred products: Kanjinti; Trazimera
If treatment can be switched to a preferred product, select preferred product and skip to criteria questions
Non-preferred product requests require documentation why patient cannot switch
If intolerance to both preferred products is claimed, attach supporting chart notes
Indicate prior receipt of requested product within past 365 days

Note

Dosing limits

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

Defined Terms and Exception Questions

Preferred product

Preferred productsKanjinti; Trazimera

RolePreferred products are the plan-preferred biosimilars — requests for non-preferred products require assessment for switching or justification

Switch questionQuestion B asks if the patient's treatment can be switched to a preferred product (Kanjinti or Trazimera)

Exception Criteria Questions

A. Product requestedChecklist of requested product options (Herceptin; Herceptin Hylecta; Herzuma; Kanjinti; Ogivri; Ontruzant; Trazimera)

B. Can switch to preferred?Yes — select Kanjinti or Trazimera to skip to Criteria Questions; No — continue to Question C

C. Prior receipt within lookbackHas the patient received the requested product in the past 365 days? Yes = skip to Criteria Questions; No = continue to D

D. Intolerance to both preferred productsDoes the patient have documented intolerable adverse events to both Kanjinti and Trazimera? If Yes, attach supporting chart notes and continue to E

E. Attribution of adverse eventWas the intolerable adverse event an expected adverse event attributed to the active ingredient per prescribing information? If 'No', attach supporting chart notes; then continue to Criteria Questions

OpenPayer

Trastuzumab and biosimilars prior authorization request form

Authorization Decision Criteria

Diagnosis and Lookback Coding

Submission, Documentation, and Product Selection

Defined Terms and Exception Questions