CurrentHawaii Medical Service Association (HMSA)Policy N/A

Repatha (PCSK9 inhibitor) prior authorization form / coverage criteria

Prior authorization request form and decision tree used by CVS Caremark for HMSA members requesting coverage for PCSK9 inhibitor therapy (Repatha). Collects patient demographics, diagnosis (ASCVD, HeFH, HoFH, primary hyperlipidemia), LDL-C values, prior lipid-lowering therapy history and statin intolerance criteria to determine approval.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyRepatha (PCSK9 inhibitor) prior authorization form / coverage criteria

Policy CodePolicy N/A

Change TypeNon-clinical/clarification (footer update)

Effective Date

Next Review Date

Key ActionFax completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512 to initiate coverage determination for PCSK9 inhibitor (Repatha).

POLICY UPDATE CHANGES

Form footer shows 'Repatha HMSA - 10/2023' indicating a non-clinical update date.

1Form covers PCSK9 inhibitor (Repatha)

>=190 mg/dLUntreated LDL-C threshold noted

>=7SAMS-CI score threshold

>=10x ULNCK increase threshold

Coverage Summary

This is a prior authorization request form used by CVS Caremark on behalf of HMSA to request coverage for Repatha (a PCSK9 inhibitor). Coverage is covered_with_criteria; approval requires completion of the form and meeting the documented criteria (diagnosis, LDL-C thresholds, prior therapy, or documented intolerance).

Key thresholds and statin examples

Untreated LDL-C threshold>= 190 mg/dL

SAMS-CI score threshold>= 7

Statin-associated CK increase threshold>= 10 times ULN

High-intensity statin examplesrosuvastatin 20 mg daily; atorvastatin 40 mg daily

Moderate-intensity statin exampleatorvastatin 20 mg daily (or equivalent)

Provider Actions and Administrative Requirements

Prior Authorization

Submit prior authorization request to CVS Caremark

Fax the completed prior authorization form to CVS Caremark Specialty Programs to initiate a coverage determination for Repatha. Use toll-free fax number 1-866-237-5512 and address the submission to CVS Caremark Specialty Programs.

Documentation Required

Provide clinical documentation of LDL-C and prior therapies

Document and make available for review: the patient's current LDL-C and untreated (pre-treatment) LDL-C values; prior statin therapy including dose and duration (high- or moderate-intensity examples provided); whether ezetimibe was used; and evidence of statin intolerance such as SAMS-CI score, statin-associated CK elevations, or listed contraindications.

Denial Risk

Incomplete criteria may delay/deny coverage

Failure to provide required documentation — including diagnosis, LDL-C values (current and/or untreated), evidence of prior adequate statin and/or ezetimibe therapy, or documentation supporting statin intolerance or contraindications — may lead to non-approval or delay of coverage.

Billing Rule

Contact numbers for questions

For prior authorization questions or help with the form, contact CVS Caremark at 1-808-254-4414. For Specialty Customer Care/CaremarkConnect inquiries (eligibility, copay, delivery), call 1-800-237-2767.

CVS Caremark: 1-808-254-4414
Specialty Customer Care / CaremarkConnect: 1-800-237-2767

Background

This prior authorization form (CVS Caremark for HMSA) captures: diagnosis selection (ASCVD, HeFH, HoFH, primary hyperlipidemia, or other); current and untreated (pre-therapy) LDL-C values (with a branch if untreated LDL-C >= 190 mg/dL or Unknown); whether the request is for continuation of PCSK9 inhibitor therapy; prior lipid‑lowering therapy details including receipt of high‑intensity statin (examples: rosuvastatin 20 mg or atorvastatin 40 mg daily) and duration (at least 3 months), use of ezetimibe in combination, or inability to tolerate high‑intensity statin leading to assessment of moderate‑intensity statin therapy (example: atorvastatin 20 mg) and duration. The form also documents statin intolerance criteria (SAMS‑CI score, creatine kinase elevations, and contraindications) to support exceptions.

Definitions: ASCVD — clinical atherosclerotic cardiovascular disease including acute coronary syndrome, myocardial infarction, angina, coronary/arterial revascularization, atherosclerotic stroke, TIA, or peripheral arterial disease; HeFH — heterozygous familial hypercholesterolemia; HoFH — homozygous familial hypercholesterolemia; SAMS‑CI — Statin‑Associated Muscle Symptom Clinical Index (score of 7 or higher indicates statin‑associated muscle symptom intolerance per the form).