CurrentHawaii Medical Service Association (HMSA)Policy N/A

Hmsafaxform_Actemra

A CVS Caremark prior authorization form (used by HMSA) governing medical coverage determination for Actemra (IV and SC) and listed biosimilars/alternatives across multiple indications; collects clinical criteria, prior therapy history, testing, prescriber info and site of administration to support PA decisions.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHmsafaxform_Actemra

Policy CodePolicy N/A

Change TypePrior authorization form (no material change)

Effective Date

Next Review Date

Key ActionFax the completed CVS Caremark Specialty Programs PA form to 1-866-237-5512 (or contact 1-808-254-4414) and include supporting documentation for prior failures/intolerance/contraindications when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief (has_material_change=false).

MultipleIndications covered (form captures)

ManyPreferred alternatives listed

1-866-237-5512PA fax number

Coverage summary

This is a CVS Caremark prior authorization (PA) request form used for HMSA members to support medical coverage determinations for Actemra (tocilizumab) in both IV and SC formulations and listed biosimilars/alternatives (e.g., Tofidence, Tyenne). The form captures the requested product and route/site of dispensing or administration, the patient diagnosis/indication, prescriber specialty and contact details, and whether the request is for continuation of therapy or a new start.

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The PA collects clinical details needed for coverage decisions, including indication-specific prior therapy history (documented inadequate response, intolerance, or contraindication to listed preferred products), safety screening such as tuberculosis (TB) and HIV testing, relevant laboratory testing, and documentation of prescriber specialty or consultation. The form routes questions by indication and contains continuation-versus-new-start logic to document prior response or ongoing benefit.

Initial therapy — criteria and required documentation

By indication

By indication: (operator = any)

ANY of the following

Ankylosing spondylitis: ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to all listed preferred products for ankylosing spondylitis (Cosentyx SQ, Enbrel, Rinvoq, Taltz, and adalimumab-adaz, Hyrimoz (Cordavis brand) or Hadlima).
ACTION REQUIRED: submit supporting documentation
Ankylosing spondylitis (IV-preferred list): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to IV preferred products (Cosentyx IV, Avsola or Inflectra IV, and Simponi Aria).
ACTION REQUIRED: submit supporting documentation
Crohn's disease (self-administered): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to ALL listed preferred products for Crohn's disease (Rinvoq, Skyrizi SQ AND Tremfya SQ; adalimumab-adaz, Hyrimoz (Cordavis) OR Hadlima; Pyzchiva SQ (Cordavis or Sandoz) OR Yesintek SQ).
ACTION REQUIRED: submit supporting documentation
Crohn's disease (IV-preferred): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to ALL listed IV preferred products for Crohn's disease (Entyvio, Skyrizi IV, AND Tremfya IV; Pyzchiva IV (Cordavis or Sandoz) OR Yesintek IV; Avsola OR Inflectra).
ACTION REQUIRED: submit supporting documentation
Plaque psoriasis (self-administered): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to ALL listed preferred products for plaque psoriasis (Cosentyx SQ, Enbrel, Otezla, Skyrizi SQ, Taltz AND Tremfya SQ; adalimumab-adaz, Hyrimoz (Cordavis) OR Hadlima; Pyzchiva SQ (Cordavis or Sandoz) OR Yesintek SQ).
ACTION REQUIRED: submit supporting documentation
Plaque psoriasis (IV-preferred): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to Avsola OR Inflectra.
ACTION REQUIRED: submit supporting documentation
Psoriatic arthritis (self-administered): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to ALL listed preferred products for psoriatic arthritis (Cosentyx SQ, Enbrel, Otezla, Rinvoq, Skyrizi SQ, Taltz, Tremfya SQ AND Xeljanz/Xeljanz XR; adalimumab-adaz, Hyrimoz (Cordavis) OR Hadlima; Pyzchiva SQ (Cordavis or Sandoz) OR Yesintek SQ).
ACTION REQUIRED: submit supporting documentation
Psoriatic arthritis (IV-preferred): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to Cosentyx IV, Avsola OR Inflectra and Simponi Aria.
ACTION REQUIRED: submit supporting documentation
Rheumatoid arthritis (self-administered): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to ALL listed preferred products for rheumatoid arthritis (Enbrel, Rinvoq, Xeljanz/Xeljanz XR, and adalimumab-adaz, Hyrimoz (Cordavis) or Hadlima).
ACTION REQUIRED: submit supporting documentation
Rheumatoid arthritis (IV-preferred): ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to both Avsola OR Inflectra and Simponi Aria.
ACTION REQUIRED: submit supporting documentation
Ulcerative colitis: ACTION REQUIRED: submit supporting documentation - documented inadequate response, intolerable adverse event, or contraindication to ALL listed preferred products for ulcerative colitis (adalimumab-adaz, Avsola, Entyvio, Hadlima, Hyrimoz (Cordavis), Inflectra, Pyzchiva IV/SQ (Cordavis or Sandoz), Rinvoq, Skyrizi IV/SQ, Tremfya IV/SQ, Velsipity, Xeljanz/Xeljanz XR, and Yesintek IV/SQ).
ACTION REQUIRED: submit supporting documentation

Exception Criteria - Adult preferred product check

Exception Criteria - Adult preferred product check: (operator = all)

ALL of the following

A. Patient is an ADULT (>= 18 years).
If No, skip to indication-specific criteria
B. Can treatment be switched to a preferred product?
- Yes - obtain and submit the PA form for the preferred product (route as appropriate).
  Submit completed PA form to CVS Caremark Specialty Programs
- No - proceed to indication-specific preferred-product failure/contraindication requirements.

Step Therapy

Provide supporting documentation for preferred-product failures

Provide supporting documentation of preferred-product failures or contraindications on the PA form.

Submit documentation of inadequate response, intolerable adverse event, or contraindication to all listed preferred products for the relevant indication.
Submit completed PA form to CVS Caremark Specialty Programs (fax to 1-866-237-5512).
Provide TB and relevant lab testing results.
Include prescriber specialty and consultation documentation.
Indicate product and route on form (e.g., Actemra IV or Actemra SC).

Continuation of therapy — criteria

Prior Authorization

Prior authorization submission

Fax the completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512 or contact CVS Caremark at 1-808-254-4414 to request prior authorization. Include required supporting documentation when submitting the form.

Safety screening and required testing

Documentation Required

TB and relevant lab testing results

Provide tuberculosis (TB) testing within 12 months and the test results; if TB positive, document whether latent TB treatment has been initiated or completed or if active TB is present and being managed. For rheumatoid arthritis, include RF and anti-CCP testing and CRP and/or ESR testing as requested on the form.

TB test within 12 months and results; if TB positive, document latent TB treatment status or active TB management; RA-specific tests RF/anti-CCP and CRP/ESR as requested on form.

Indication-specific clinical and prescriber requirements

Documentation Required

Prescriber specialty / consultation documentation

Document the prescriber specialty or that the prescriber is consulting with the required specialist (rheumatologist, oncologist/hematologist, or pulmonologist) as indicated by the diagnosis-specific questions on the form.

Document prescriber specialty or consultation (rheumatologist, oncologist/hematologist, pulmonologist) as required per indication.

Products listed on form and preferred alternatives

Products listed on formmixedCovered

Actemra SC	tocilizumab subcutaneous formulation (requested product option on form)
Actemra IV	tocilizumab intravenous formulation (requested product option on form)
Tofidence IV	listed biosimilar/alternative (IV) on form
Tofidence SQ	listed biosimilar/alternative (SC) on form
Tyenne IV	listed biosimilar/alternative (IV) on form
Tyenne SQ	listed biosimilar/alternative (SC) on form

Preferred products by indication (examples from form)mixedCovered

adalimumab-adaz	preferred product listed for multiple indications
Avsola	preferred infliximab biosimilar
Cosentyx IV/SQ	secukinumab (IV/SQ)
Enbrel	etanercept
Hadlima	adalimumab biosimilar
Hyrimoz (Cordavis brand)	adalimumab biosimilar
Inflectra	infliximab biosimilar
Rinvoq	upadacitinib
Simponi Aria	golimumab IV
Taltz	ixekizumab

1–10 of 18

1/2

Billing Rule

Product, route, and site must be specified

Indicate the exact product requested and the route of administration on the prior authorization form, and specify the site of dispensing or administration.

Specify exact product requested (Actemra IV/SC or listed biosimilars) and route (IV vs SC) and site of dispensing/administration on the PA form.

Provider actions and submission instructions

Prior Authorization

Prior authorization submission

Fax the completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512 or contact CVS Caremark at 1-808-254-4414. When submitting, include supporting documentation for prior failures, intolerances, or contraindications as required by the form.

Documentation Required

Supporting documentation for preferred-product failures or contraindications

Attach evidence of inadequate response, intolerable adverse event, or contraindication to the listed preferred products for the patient’s indication when submitting the PA form.

Attach evidence of inadequate response/intolerance/contraindication to listed preferred products per indication.

Background and definitions

This PA request form is administered by CVS Caremark for HMSA patients to determine coverage for Actemra (tocilizumab) and listed biosimilars/alternatives across multiple inflammatory, rheumatologic, oncologic and transplant-related indications. Providers are instructed to fax the completed form to CVS Caremark Specialty Programs and to include supporting documentation as requested.

The form routes by indication and documents whether the product is self-administered or not, the exact product requested (Actemra IV/SC or listed biosimilars such as Tofidence or Tyenne), and the site of dispensing/administration. For many indications the form requires documentation of prior inadequate response, intolerable adverse event, or contraindication to all listed preferred products for that indication and explicitly requests submission of supporting documentation.

Standard safety screening and concomitant-therapy questions are included (for example, whether the drug will be used with another biologic or targeted synthetic agent, prior exposure to agents associated with TB risk, TB testing within 12 months, and HIV/herpesvirus-8 testing where relevant). The form also routes continuation requests differently from new-start requests and asks for evidence of a positive clinical response or justification for dose changes when applicable.

Positive clinical response: defined in the form as evidence of benefit since starting therapy — examples include low disease activity or, for rheumatoid arthritis, a measurable improvement such as at least 20% improvement from baseline in tender joint count, swollen joint count, pain, or disability. The form also accepts other condition-specific improvements (e.g., reduced number of active joints, improved functional ability, improvement in systemic features for sJIA, or improvement in CRP/ESR) as evidence of positive clinical response.

Other definition entries (implied by the flow of questions): “continuation of therapy” refers to requests for patients already receiving the requested drug or a biosimilar (including via samples or manufacturer assistance programs) and requires documentation of maintained clinical response; “initial therapy” or new starts require documentation of prior conventional or preferred biologic/targeted synthetic therapy failures or appropriate biomarker/lab testing per indication.

Clinical evidence notes

No formal clinical trial evidence or trial summaries are provided on the PA form. The document is focused on administrative prior authorization criteria and requests supporting clinical documentation (e.g., prior therapy failures, TB/HIV testing, biomarker results, and prescriber specialty) rather than summarizing clinical trials or evidence.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHmsafaxform_Actemra

Policy CodePolicy N/A

Change TypePrior authorization form (no material change)

Effective Date

Next Review Date

SourceLink

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