CurrentHawaii Medical Service Association (HMSA)Policy N/A

QUEST Fax Prior Authorization Request Form for Specialty Medications

A prior authorization request fax form (HMSA/CVS Caremark) to collect patient, prescriber, and clinical criteria information for coverage determination of certain prescription medications (notably biologics/targeted therapies for atopic dermatitis). It captures required clinical responses, documentation attachments, site of care, and instructions for faxing or contacting Caremark.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyQUEST Fax Prior Authorization Request Form for Specialty Medications

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete the form and fax to CVS Caremark toll-free at 1-866-237-5512 for prior authorization determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted.

14Form Questions

180dPrior therapy lookback period

2Required failed topical therapy classes

Document overview

This is a prior authorization request fax form used by HMSA/CVS Caremark to collect patient, prescriber, and clinical criteria information to determine coverage for certain specialty medications. CVS Caremark administers the prescription benefit plan for HMSA members and requires prior authorization for some drugs; providers must fax the completed form to CVS Caremark at 1-866-237-5512 (questions: 1-808-254-4414; specialty inquiries: CaremarkConnect 1-800-237-2767).

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The form specifically targets biologic and systemic targeted therapies for moderate-to-severe atopic dermatitis and collects demographics (including weight, height, and ICD-10 code), prescriber details (name, specialty, NPI, contact), site of drug dispensing and administration, sequential clinical criteria questions (age, weight, prior/continuing therapy status, prior biologic/targeted therapy within 180 days, body surface area, involvement of crucial areas), prior therapy history (failed topical therapies — requirement of failure to two specified classes within 180 days), and indicates required attachments (chart notes, medical records, or claims history) and prescriber attestation/signature.

Clinical criteria (form flow)

General form flow / Prior authorization clinical questions

Complete the form and answer sequential criteria questions; attachments required where indicated.

General patient and administrative data

Provide patient demographics, prescriber information, site of drug dispensing and administration, ICD-10 code, weight, height.

Diagnosis options

Atopic dermatitis, moderate-to-severe
Other

ALL of the following

Yes
Continue to next question
No
Continue to next question

ALL of the following

Yes
Continue to next question
No
Continue to next question

ALL of the following

Yes
Continue to next question
No
Continue to next question

ALL of the following

Yes
Continue to next question
No
Continue to next question

Continuation vs New therapy

Continuation branch
- ANY of the following
  - Yes
    Continue to Q8
  - No
    If No, proceed to Q10
- If previously authorized -> sample/assistance status
  - Yes
    Continue to Q10
  - No
    Continue to Q9

Prior biologic / systemic use

Yes
Attach documentation; No further questions
No
Continue to Q11

BSA assessment

Less than 10% of BSA< 10%
Continue to Q12
Greater than or equal to 10% of BSA>= 10%
Continue to Q13

Crucial body areas

Yes
Attach documentation; Continue to Q13
No
Continue to Q13

Prerequisite topical failures

Yes
Attach documentation; No further questions
No
Continue to Q14

Topical therapy exceptions

Yes
Attach clinical documentation; No further questions
No
No further questions

Attestation: Prescriber signature and date attesting accuracy and availability of documentation for review.

Prescriber or authorized signature required

What providers must do

Prior Authorization

Fax prior authorization to CVS Caremark

Complete the form and fax to CVS Caremark toll-free at 1-866-237-5512 for prior authorization determination. For questions, contact CVS Caremark at 1-808-254-4414. For specialty inquiries related to eligibility, copay, or medication delivery, contact the Specialty Customer Care Team: CaremarkConnect 1-800-237-2767.

Documentation Required

Attach clinical documentation for prior therapies and response

Attach chart notes, medical record documentation, or claims history where indicated on the form to support prior medications tried, body surface area, and clinical response. Attachments are explicitly required for Questions 9, 10, 11, 12, 13, and 14 per the form instructions.

Documentation Required

Clinical attestation signature required

The prescriber or authorized signatory must sign and date the form attesting that the information is accurate and that documentation supporting the information is available for review by CVS Caremark or the benefit plan sponsor.

Billing Rule

Site of care / administration reporting

Indicate the site where the drug is being dispensed and the site where the drug is being administered by selecting the appropriate option(s) on the form. Multiple site choices are provided for both dispensing (e.g., office, outpatient hospital, pharmacy, skilled nursing facility, etc.) and administration (e.g., ambulatory surgical, home, inpatient hospital, office, outpatient hospital, pharmacy).

Background & definitions

CVS Caremark administers the prescription benefit plan for HMSA members and certain medications require prior authorization for coverage; providers are instructed to fax this form to CVS Caremark to allow an appropriate determination.

The form focuses on biologic and targeted therapies for moderate-to-severe atopic dermatitis and collects patient demographics (including weight, height, and ICD-10 diagnosis), prescriber information (name, specialty, NPI, contact), the site of dispensing and administration, clinical criteria questions (age ≥ 12 years, weight ≥ 40 kg, continuation vs new therapy, prior biologic/targeted therapy within 180 days, body surface area less than 10% vs ≥10%, and crucial body areas involved), prior therapy history including failure of two specified topical therapy classes within 180 days, and required documentation attachments (chart notes, medical records, or claims history) along with prescriber attestation and signature.

Definitions

PAPManufacturer's patient assistance program (referred to regarding receipt of drug via samples or assistance)

OpenPayer

QUEST Fax Prior Authorization Request Form for Specialty Medications

Document overview

Clinical criteria (form flow)

Coding guidance

What providers must do

Background & definitions

Revision history