CurrentHawaii Medical Service Association (HMSA)Policy N/A

QUEST Fax Form

A prior authorization request form used by HMSA/CVS Caremark for specialty prescription benefit review of rituximab products (Rituxan, Riabni, Ruxience, Truxima) across multiple indications; collects patient/provider data, indication-specific screening questions, and re-authorization evidence requirements to facilitate coverage decisions.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyQUEST Fax Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and fax the form with required clinical documentation to CVS Caremark Specialty Programs at 1-866-237-5512 to request prior authorization for rituximab products.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes reported.

4Rituximab products listed

18Indication pathways on form

1-866-237-5512Primary fax number

Policy Overview

This form is the QUEST prior authorization fax used by HMSA/CVS Caremark to request coverage review for rituximab products. It lists the requested products as Rituxan, Riabni, Ruxience, and Truxima and collects patient and prescriber administrative data, diagnosis (ICD-10), indication-specific clinical screening questions, and documentation to support initial or re‑authorization decisions. The form is intended to support multiple autoimmune, hematologic, neurologic, renal, and oncologic indications by directing the requester to the appropriate indication pathway on the questionnaire.

High-level authorization constraints are noted on the form: approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and evidence-based practice guidelines. For rheumatoid arthritis the form specifically documents a threshold of an inadequate response after at least 3 months of methotrexate at a dose ≥ 15 mg per week as part of the authorization pathway. The form instructs providers to fax completed requests and supporting documentation to CVS Caremark Specialty Programs at 1-866-237-5512 (with additional contact numbers for questions).

Indication-Specific Authorization Criteria

General Intake and Indication Selection

Select diagnosis and follow the indicated question pathway for that diagnosis.

ANY of the following

Rheumatoid arthritis (RA) -> continue to RA pathway (#2)
Wegener's granulomatosis (granulomatosis with polyangiitis) or microscopic polyangiitis -> continue to #100
Non-Hodgkin's lymphoma (NHL) -> continue to #900
Chronic lymphocytic leukemia (CLL) -> continue to #900
Small lymphocytic lymphoma (SLL) -> continue to #900
Pemphigus vulgaris -> continue to #750
Leptomeningeal metastases from lymphomas -> continue to #900
Primary CNS lymphoma -> continue to #900
Waldenström's macroglobulinemia/lymphoplasmacytic lymphoma (LPL) -> continue to #900
Acute lymphoblastic leukemia (ALL) -> continue to #900
Hodgkin's lymphoma -> continue to #900
Myasthenia gravis -> continue to #700
Immunotherapy-related toxicities -> continue to #800
Autoimmune hemolytic anemia -> continue to #800
Immune or idiopathic thrombocytopenic purpura -> continue to #800
Thrombotic thrombocytopenic purpura -> continue to #800
Membranous nephropathy -> continue to #150
Other -> No Further Questions
Terminal node: No Further Questions

Rheumatoid Arthritis Initial Authorization Pathway

Covered when following assessment questions are completed; answers guide authorization decision.

ALL of the following

Prior rituximab authorization
- Prescribed by or in consultation with immunologist, rheumatologist or nephrologist
  Question #2 (Yes/No)
- ANY of the following
  - Previously authorized by HMSA/CVS -> go to re-authorization (#15)
  - Not previously authorized or unknown -> continue initial authorization questions (#5 onward)
Methotrexate/leflunomide use or intolerance

Rheumatoid Arthritis Re-authorization Criteria

Re-authorization requires evidence of benefit.

ANY of the following

Member benefitted from treatment evidenced by low disease activity
Member benefitted from improvement in signs and symptoms
Member benefitted by maintenance of improvement in signs and symptoms
No benefit observed (documented) -> No Further Questions
Terminal node: No Further Questions

Wegener's Granulomatosis / Microscopic Polyangiitis

Initial and re-authorization pathway.

ALL of the following

Prescribed by or in consultation with immunologist, rheumatologist or nephrologist (#100)
ANY of the following
- Previously authorized -> continue to re-authorization (#102)
- Not previously authorized or unknown -> No Further Questions (initial requires prior authorization?)

Re-authorization evidence (#102)

Low disease activity measured by standardized tool (e.g., Birmingham Vasculitis Activity Score)

Membranous Nephropathy

Initial and re-authorization pathway.

ALL of the following

Prescribed by or in consultation with a nephrologist (#150)
ANY of the following
- Previously authorized -> continue to re-authorization (#152)
- Not previously authorized or unknown -> continue to initial authorization (#153)

Re-authorization evidence (#152)

Low disease activity

Myasthenia Gravis, Pemphigus Vulgaris, Autoimmune Hematologic Disorders, Immunotherapy Toxicities, TTP, Oncologic Indications

Indication-specific flow: document prescriber specialty, prior authorization history, and evidence of benefit or refractory status as applicable.

ANY of the following

Myasthenia gravis: prescribed by immunologist/neurologist/rheumatologist; prior authorization history -> re-authorization requires evidence of benefit (#700-#702)
Prescriber specialty and re-auth flow (#700-#702)
Pemphigus vulgaris: prescribed by immunologist/dermatologist; disease severity (moderate to severe) for initial auth; re-auth requires evidence of benefit (#750-#753)
Prescriber specialty, severity and re-auth (#750-#753)
Autoimmune hemolytic anemia: refractory to steroids -> initial auth (#810)
Refractory to steroids (#810)
Immune thrombocytopenic purpura:

Codes & Product List

Requested Productsmixed

Rituxan	Rituximab product (brand)
Riabni	Biosimilar rituximab
Ruxience	Biosimilar rituximab
Truxima	Biosimilar rituximab

ICD-10ICD-10

ICD-10

Form requests the ICD-10 code for diagnosis; specific codes not listed on form

Submission & Documentation Requirements

Prior Authorization

Fax prior authorization to CVS Caremark Specialty Programs

Complete and fax this prior authorization form with required clinical documentation to CVS Caremark Specialty Programs at 1-866-237-5512.

Documentation Required

Attach supportive clinical documentation for oncologic and re-authorization requests

For oncology and re-authorization requests, attach relevant clinical documentation such as office visit notes and applicable studies that demonstrate the diagnosis, the oncology regimen, and evidence of benefit (for example, positive clinical response or lack of disease progression).

Office visit notes
Applicable studies
Diagnosis documentation
Regimen details
Evidence of benefit (response or lack of progression)

Documentation Required

Document prescriber specialty and prior authorization history

Indicate the prescriber's specialty (examples include immunologist, rheumatologist, nephrologist, neurologist, dermatologist, hematologist/oncologist) on the form and indicate whether rituximab was previously authorized by HMSA/CVS for this member.

Prescriber specialty field (e.g., immunologist, rheumatologist, nephrologist, neurologist, dermatologist, hematologist/oncologist)
Prior rituximab authorization status (Yes / No / Unknown)

Documentation Required

Record biomarker and treatment trial results for RA

For rheumatoid arthritis initial authorization, provide results of biomarker testing (rheumatoid factor [RF], anti-CCP, and C-reactive protein [CRP] and/or erythrocyte sedimentation rate [ESR]) as applicable and documentation of a methotrexate trial showing inadequate response after at least 3 months at a dose ≥15 mg per week, or documentation of intolerance or a contraindication to methotrexate.

RF and/or anti-CCP test results
CRP and/or ESR results
Methotrexate trial: ≥3 months at ≥15 mg/week with inadequate response, or
Documentation of intolerance or specific contraindication to methotrexate

Form Background & Definitions

This is a specialty prior authorization fax form used by HMSA/CVS Caremark to collect the clinical and administrative information necessary to determine coverage for rituximab products across multiple indications. The form collects prescriber specialty, patient demographics, ICD-10 diagnosis, indication-specific screening questions, prior authorization history, and requires attachment of supportive clinical documentation as applicable.

The form notes that approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and evidence-based practice guidelines, and directs completed requests to be faxed to CVS Caremark Specialty Programs at 1-866-237-5512.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyQUEST Fax Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete and fax the form with required clinical documentation to CVS Caremark Specialty Programs at 1-866-237-5512 to request prior authorization for rituximab products.

SourceLink

On This Page

Used in combination with methotrexate or leflunomide -> continue to #7

Contraindication or history of intolerance to methotrexate or leflunomide -> continue to #7

Neither -> continue to #7

Prior biologic/targeted therapy

Has received a biologic or targeted synthetic drug indicated for moderate-severe RA (e.g., Rinvoq, Xeljanz) -> authorization pathway ends (No Further Questions)
Has not received such a biologic/targeted drug -> continue to biomarker testing questions

Biomarker testing

Tested positive for RF OR anti-CCP -> continue to #10
Tested for RF, anti-CCP AND CRP and/or ESR (all) -> continue to #10
No biomarker testing -> continue to #10

Methotrexate response

Inadequate response after ≥3 months of methotrexate at dose ≥15 mg/week -> No Further Questions (meets condition)>=3 months at >=15 mg/week
No inadequate response -> continue through intolerance/contraindication questions (#11-#14) to document intolerance, contraindication, or inadequate response to other conventional DMARDs

Improvement in signs and symptoms

Maintenance of improvement in signs and symptoms

No benefit observed

Terminal node: No Further Questions

Improvement in signs and symptoms

Maintenance of improvement in signs and symptoms

No benefit observed

Terminal node: No Further Questions

Initial authorization (#153)

Member at high risk for disease progression -> No Further Questions
Member not at high risk -> No Further Questions

Immune/idiopathic thrombocytopenic purpura: refractory to steroids or IVIG -> initial auth (#820)

Refractory to steroids/IVIG (#820)

Thrombotic thrombocytopenic purpura: refractory to plasma exchange or steroids -> initial auth (#830)

Refractory to plasma exchange or steroids (#830)

Immunotherapy-related encephalitis: exclusion of viral causes, antibody testing, and trial of methylprednisolone +/- IVIG with limited/no improvement -> initial auth (#803-#806)

Steps #803-#806

Oncologic indications: list regimen agents, single vs multiple agents, provide diagnosis ICD-10 and supportive data; authorization if FDA-approved or NCCN I/I A supported (#900-#905)

Oncology documentation and evidence (#900-#905)

OpenPayer

QUEST Fax Form

Policy Overview

Indication-Specific Authorization Criteria

Codes & Product List

Submission & Documentation Requirements

Form Background & Definitions

Revision History