CurrentHawaii Medical Service Association (HMSA)Policy HMSAMCD C19351-A

QUEST Fax Form

A prior authorization request form and decision checklist used by CVS Caremark on behalf of HMSA Medicaid (HMSAMCD) to determine medical necessity and approve coverage for specified biologic drugs (Actemra, Tofidence, Tyenne) across multiple indications; includes condition-specific branching criteria for initial and continuation therapy, required prescriber specialty, prior therapy, testing, and response documentation.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyQUEST Fax Form

Policy CodePolicy HMSAMCD C19351-A

Change Typeclarified

Effective Date

Next Review Date

Key ActionFax completed form with required patient, prescriber, diagnosis, product selection, testing and prior therapy responses to CVS Caremark at 1-866-237-5512 for determination; contact numbers provided for questions.

SourceLink

POLICY UPDATE CHANGES

Form updated with product listing (Actemra, Tofidence, Tyenne) and questionnaire branching for multiple indications.

11Indications listed

3Products listed

>=2Pediatric age threshold (years)

Coverage Summary

This CVS Caremark-administered prior authorization fax form (used for HMSA Medicaid, HMSAMCD C19351-A) is a decision checklist to determine medical necessity and coverage for specified biologic products (Actemra, Tofidence, Tyenne) across multiple labeled and off‑label indications. The form requires the prescriber to provide patient and prescriber demographics, indicate the product requested and ICD-10 diagnosis, specify dispensing and administration site, and complete condition‑specific branching questions that address prescriber specialty, prior therapy, testing (e.g., TB), and clinical response to support a covered_with_criteria determination.

Indication-specific Criteria (branching by diagnosis)

Indication branching

Select one diagnosis; each leads to its own criteria sequence (RA, pJIA, sJIA, GCA, SSc-ILD, Castleman disease, immunotherapy toxicities, CRS, aGVHD, polymyalgia rheumatica, other).

Rheumatoid arthritis (100+)

Core criteria: Diagnosed with moderately to severely active rheumatoid arthritis; Age: adult; Prescribed by or in consultation with a rheumatologist
Questions 100-102
Continuation vs Initial
- Continuation: If continuation (Q103=yes): confirm receiving drug via samples/PAP? (Q104); if not via samples, document positive clinical response (Q105) and substantial improvement (>= ~20% from baseline in tender/swollen joints, pain, or disability) (Q106) OR if dosing increase requested (Q107)20% improvement example
  Questions 103-107
- Initial: If initial (Q103=no): prior biologic/targeted synthetic use excludes new approval (Q150=yes -> no further questions). If no prior biologic (Q150=no) then biomarker testing requirements: either RF+ or anti-CCP+ (Q151) OR tested for RF, anti-CCP, and CRP/ESR (Q152)
  Questions 150-152

Articular juvenile idiopathic arthritis / Oligoarticular JIA (200+)

Core criteria: Diagnosed with active articular JIA; Age >= 2 years; Prescribed by or in consultation with a rheumatologist>=2 years
Questions 200-202
Continuation vs Initial
- Continuation: If continuation (Q203=yes): if not receiving via samples/PAP (Q204=no/unknown) document positive clinical response/low disease activity (Q205) and improvement in joints/functional ability (Q206)
  Questions 203-206
- Initial: If initial (Q203=no): prior biologic use for JIA excludes new approval (Q207=yes). If no prior biologic (Q207=no) then must have inadequate response to methotrexate or another conventional systemic (Q208=yes) and inadequate response to scheduled NSAIDs and/or intra-articular glucocorticoids (Q209=yes) unless high-risk features present (Q210) or other severity risk factors (Q211) or high-risk joints/high disease activity (Q212)

Systemic juvenile idiopathic arthritis (sJIA) (300+)

Core criteria: Age >= 2 years; Prescribed by or in consultation with a rheumatologist>=2 years
Questions 300-301
Continuation vs Initial
- Continuation: If continuation: if not samples/PAP (Q303=no) document positive clinical response/low disease activity and improvement in joints, function, or systemic features (Q304-Q305)
  Questions 302-305
- Initial: If initial: prior biologic use for sJIA excludes new approval (Q307=yes). If no prior biologic (Q307=no) presence of active systemic features (fever, rash, lymphadenopathy, hepatosplenomegaly, serositis) may qualify (Q308)
  Questions 306-308

Unicentric Castleman disease (375+)

Core criteria: Prescribed by or in consultation with an oncologist or hematologist
Question 375
Continuation vs Initial
- Continuation: If continuation (Q377): if not via samples/PAP (Q377=no) assess unacceptable toxicity or disease progression on current regimen (Q378)
  Questions 376-378
- Initial: If initial: HIV testing (Q379) and result (Q380); HHV-8 testing (Q381-382) and result (Q383); disease progressed after relapsed/refractory or unresectable (Q383); single-agent use (Q384); route IV vs SC (Q385)
  Questions 379-385

Multicentric Castleman disease (400+)

Core criteria: Prescribed by or in consultation with an oncologist or hematologist
Question 400
Continuation vs Initial
- Continuation: If continuation (Q401/402): if not via samples/PAP (Q402=no) assess toxicity or progression (Q403)
  Questions 401-403
- Initial: If initial: substitute for siltuximab shortage? (Q404); disease progressed after relapsed/refractory disease (Q405); single-agent use (Q406); route IV vs SC (Q407)
  Questions 404-407

Immunotherapy-related toxicity / inflammatory arthritis (425,428+)

Core criteria: Prescribed by or in consultation with an oncologist/hematologist (Q425) or oncologist/hematologist/rheumatologist (Q428); For toxicity: inadequate response or intolerance to systemic corticosteroids (Q426) OR contraindication to corticosteroids (Q427) may qualify
Questions 425-427
Continuation vs Initial - inflammatory arthritis
- Continuation: For inflammatory arthritis continuation: document current therapy status and positive clinical response (Q429-Q431)
  Questions 429-431
- Initial: moderate or severe immunotherapy-related inflammatory arthritis (Q432); inadequate response to corticosteroids or conventional synthetic DMARDs (Q433) or intolerance/contraindication to corticosteroids or conventional synthetic drugs (Q434-Q435)
  Questions 432-435

Giant cell arteritis (500+)

Core criteria: Adult patient; Prescribed by or in consultation with a rheumatologistadult
Questions 500-501
Continuation vs Initial
- Continuation: If continuation: document positive clinical response and improvement in listed symptoms (Q502-Q505)
  Questions 502-505
- Initial: diagnosis confirmed by temporal artery biopsy or cross-sectional imaging (Q506) OR confirmed by elevated acute-phase reactants (ESR/CRP) (Q507)
  Questions 506-507

Cytokine release syndrome (600+)

Core criteria: Prescribed by or in consultation with an oncologist or hematologist; Indication is prophylaxis or treatment of CRS; Route of administration: IV or SC
Questions 600-602

Acute graft versus host disease (625+)

Core criteria: Prescribed by or in consultation with an oncologist or hematologist; Inadequate response to systemic corticosteroids or intolerance/contraindication to corticosteroids; Route of administration: IV or SC
Questions 625-628

Systemic sclerosis-associated interstitial lung disease (650+)

Core criteria: Adult patient; Prescribed by or in consultation with a rheumatologist or pulmonologistadult
Questions 650-651
Continuation vs Initial
- Continuation: If receiving drug via samples/PAP (Q653=yes) then continue; if not via samples/PAP (Q653=no) No Further Questions (per form)
  Question 653
- Initial: diagnosis confirmation by high-resolution CT chest may be requested (Q654)
  Question 654

Polymyalgia rheumatica (675+)

Core criteria: Prescribed by or in consultation with a rheumatologist
Question 675
Continuation vs Initial
- Continuation: If continuation: if not samples/PAP (Q677=no) document positive clinical response/low disease activity and improvement in morning stiffness, hip/shoulder pain or ROM, or CRP/ESR (Q678-Q679)
  Questions 676-679
- Initial: inadequate response to systemic corticosteroids (Q680) or disease flare during steroid taper (Q681) or inadequate response to methotrexate (Q682); intolerance/contraindication to corticosteroids or methotrexate (Q683-Q684) with specified contraindications (Q685)
  Questions 680-685

Provider Actions & Requirements

Prior Authorization

Submit prior authorization via fax

Fax the completed prior authorization form to CVS Caremark at 1-866-237-5512 for determination. Include required patient and prescriber demographics, diagnosis, product selection, TB/HIV/HHV-8 testing responses (where applicable), prior therapy history, and clinical response information as indicated on the form.

For questions regarding the prior authorization call CVS Caremark at 1-808-254-4414; for Specialty Customer Care (eligibility, copay, delivery) call CaremarkConnect at 1-800-237-2767.

Documentation Required

Document prior therapy and clinical response

Provide documentation of prior biologic or targeted synthetic therapy status and trials of conventional systemic therapies where required. For continuation requests, document objective clinical improvement or maintenance of response as specified on the form. Include biomarker and infection testing results when indicated by the diagnosis-specific questions.

Biomarker tests: rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), and C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR).
Infection screening tests where indicated: tuberculosis (TST/IGRA within 12 months), HIV, and herpesvirus‑8 (HHV‑8).
Prior conventional therapy trials (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine) and inadequate response to NSAIDs or intra‑articular glucocorticoids when required.
For continuation: objective measures such as low disease activity, improvement in tender/swollen joint counts, number of active joints, functional ability, systemic features, or ≥~20% improvement from baseline in RA measures as applicable.

Documentation Required

Specialist prescriber requirement

Many indications on the form require that the requested drug be prescribed by, or in consultation with, a relevant specialist. Confirm prescriber specialty or consultation as specified for the diagnosis being requested.

Check the indication-specific question(s) on the form to confirm whether a rheumatologist, oncologist/hematologist, or pulmonologist is required for that diagnosis.

Billing Rule

Dosing limits adherence

Approvals may be subject to dosing limits consistent with FDA‑approved labeling, accepted compendia, and evidence‑based practice guidelines; ensure requested dosing and frequency adhere to these limits.

Documentation Required

Attestation and documentation availability

The prescriber (or authorized signatory) must sign the attestation on the form confirming that the information provided is accurate and that supporting documentation is available for review by CVS Caremark or the benefit plan sponsor.

OpenPayer

QUEST Fax Form

Coverage Summary

General Authorization Requirements

Indication-specific Criteria (branching by diagnosis)

Product Selection / Codes

Provider Actions & Requirements

Background / Purpose

Revision History

	Actemra (product listed on form)
	Tofidence (product listed on form)
	Tyenne (product listed on form)