CVS Caremark Prior Authorization Request — Biologic Therapy for SLE and Lupus Nephritis
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This is a CVS Caremark prior authorization form used by HMSA to collect clinical and demographic information to determine coverage for certain medications (notably biologics) for patients with systemic lupus erythematosus (SLE) or active lupus nephritis; it affects prescribers and pharmacy/specialty benefit administrators processing prior authorizations.
No material clinical or coverage changes in this revision.
Coverage Criteria for Biologic Therapy in SLE / Lupus Nephritis
Initial and continuation medical necessity criteria
Covered when the following branching initial and continuation conditions are met. Start by indicating diagnosis and whether the patient is currently receiving the requested medication; follow the continuation pathway if currently receiving, otherwise follow the initial pathway.
Supported by form flow
Q3-4
Q10-11
Q12
Q20-21
Q30-31
The form explicitly asks whether the patient will be treated with the requested biologic in combination with other biologic agents. This combination-use question appears in both the continuation and initial evaluation pathways and serves as a gating item that can alter further review steps. Providers must answer the combination therapy question as part of the PA submission so the reviewer can determine whether to proceed with the standard criteria pathway or stop additional questions.
If the provider indicates the medication will be used in combination with other biologics, the form directs "No Further Questions" at that step. In the continuation section the combination question (Q4) provides the two options with the label "No Further Questions"; the initial section contains the same combination question (Q11) which likewise controls progression through the form. This reflects that combination biologic use is handled as a distinct case that halts the usual criteria flow and requires no additional routine PA questions on this form.
Requested Diagnosis and Coding
| ICD-10 field | Space on form to enter the ICD-10 code for the diagnosis |
Provider Actions, Prior Authorization and Documentation
Prior authorization and submission
Prior authorization is required for certain medications administered through CVS Caremark. Fax completed prior authorization forms and supporting documentation to CVS Caremark toll-free at 1-866-237-5512. For questions regarding prior authorization determinations, contact CVS Caremark at 1-808-254-4414. For patient eligibility, copay, or medication delivery inquiries, contact CaremarkConnect® Specialty Customer Care Team at 1-800-237-2767. Provide the most accurate diagnosis for the prescribed medication when submitting the request. Approvals may be subject to dosing limits per FDA labeling, accepted compendia, and evidence-based practice guidelines.
- Fax prior authorization form and documentation to: 1-866-237-5512
- Prior authorization questions: 1-808-254-4414
- Specialty Customer Care (CaremarkConnect®): 1-800-237-2767
Expectations about prior or concurrent standard therapy
Before initiating therapy for systemic lupus erythematosus (SLE) or active lupus nephritis, documentation of prior or concurrent standard treatment regimens is expected. For SLE, document use of glucocorticoids (e.g., prednisone), antimalarials (e.g., hydroxychloroquine), and/or immunosuppressives (e.g., azathioprine, methotrexate, mycophenolate). For lupus nephritis, document use of standard agents such as cyclophosphamide, mycophenolate mofetil, azathioprine, and/or glucocorticoids. Attach medical records demonstrating prior or current standard therapy when indicated on the form.
- SLE — document prior/concurrent: glucocorticoids, antimalarials, and/or immunosuppressives
- Lupus nephritis — document prior/concurrent: cyclophosphamide, mycophenolate mofetil, azathioprine, and/or glucocorticoids
Required supporting documentation
Attach supporting clinical documentation with the prior authorization request. For continuation requests or where indicated, include chart notes, laboratory reports (including autoantibody testing such as ANA, anti-dsDNA, anti-Sm, antiphospholipid antibodies, complement levels), and biopsy results (e.g., kidney biopsy confirming lupus nephritis) as applicable. If the request is for continuation of therapy, include records demonstrating maintained or improved clinical response (disease stability or symptom improvement).
- Attach chart notes and progress notes documenting clinical status
- Include lab reports (e.g., ANA, anti-dsDNA, anti-Sm, antiphospholipid antibodies, complement proteins)
- Include biopsy reports when relevant (e.g., kidney biopsy for lupus nephritis)
- For continuation requests, attach documentation of disease stability or improvement
Documentation-based denial risk
Failure to submit required supporting documentation or to provide an accurate and specific diagnosis may result in denial of the prior authorization request. Ensure all requested fields on the form are completed and that documentation is available for review upon request by CVS Caremark or the benefit plan sponsor.
- Incomplete forms or missing attachments may lead to denial
- Provide accurate diagnosis and attest to availability of supporting documentation
Definitions and Key Clinical Findings
Background
This prior authorization form is designed to collect the clinical and treatment information necessary to assess appropriateness of a biologic or other specialty medication for patients with active systemic lupus erythematosus (SLE) or active lupus nephritis. It captures diagnosis, disease-specific screening (for example, severe active CNS lupus), prior and current therapies, and whether the biologic will be used in combination with other biologics to guide initial or continuation coverage decisions.
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