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A prior authorization questionnaire/form used by CVS Caremark for HMSA members to determine coverage eligibility for certain biologic or targeted synthetic medications across indications including CAPS, DIRA, and recurrent pericarditis; gathers clinical, demographic, TB screening, prior therapy and prescriber specialty information and requires documentation attachments for approvals.
No material clinical or coverage changes for this policy.
Coverage Summary
This document is a CVS Caremark prior authorization form used for HMSA commercial benefit plans and the coverage stance is covered_with_criteria. The form is a questionnaire to determine eligibility for certain biologic or targeted synthetic medications and collects patient demographics and dispensing/administration site information. It requires documentation of tuberculosis (TB) screening (e.g., TST, IGRA) within 6 months of initiating therapy, prior exposure to biologic or targeted synthetic agents, and indication-specific documentation (e.g., diagnosis confirmation, genetic testing, or response documentation) to support coverage decisions.
Coverage Criteria (form-driven decision trees)
General screening and TB questions
Complete all items to determine TB risk and concomitant biologic use
CAPS (initial and continuation)
Coverage contingent on age, prescriber specialty, and response/diagnosis documentation
ALL of the following
- Is the patient 12 years of age or older?>= 12 years
Form asks regardless of answer
- Is the requested drug prescribed by or in consultation with a rheumatologist or immunologist?
Yes/No — continue
Therapy type
Continuation of therapy
- Is this request for continuation of therapy with the requested drug?
Is this request for continuation of therapy? (Yes/No)
- If currently receiving via samples or manufacturer's PAP
Currently receiving through samples or manufacturer's PAP? (Yes/No/Unknown)
- Has the patient achieved or maintained positive clinical response as evidenced by low disease activity or improvement in signs and symptoms since starting treatment with the requested drug?
If Yes -> attach documentation; Yes -> No Further Questions
Initial therapy
- Which is the patient's diagnosis (FCAS or MWS)?
Form asks regardless
- For FCAS: classic signs/symptoms (recurrent intermittent fever and rash often exacerbated by cold)?
Yes/No
- For MWS: classic signs/symptoms (chronic fever and rash waxing/waning, sometimes cold-exacerbated)?
Yes/No
- Does the patient have functional impairment limiting activities of daily living?
Yes/No — form ends
DIRA (initial and continuation)
Coverage contingent on weight, prescriber specialty, mutation status, and prior anakinra use
ALL of the following
- Does the patient weigh 10 kg or more?>= 10 kg
- Is the requested drug being prescribed by or in consultation with a rheumatologist or immunologist?
Therapy type
Continuation of therapy
- Is this request for continuation of therapy with the requested drug?
Is this request for continuation of therapy? (Yes/No)
- If currently receiving via samples or manufacturer's PAP
Currently receiving through samples or manufacturer's PAP? (Yes/No/Unknown)
- Has the patient achieved or maintained a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms since starting treatment with the requested drug?
If Yes -> No Further Questions
Initial therapy
- Does the patient have IL1RN mutations?
ACTION REQUIRED: If 'Yes', please attach documentation of IL1RN mutation status
- Will the requested drug be used for maintenance of remission following treatment with Kineret (anakinra)?
Yes/No
Coding
| No codes listed |
Required Provider Actions
Submit prior authorization form to CVS Caremark
Fax the completed HMSA prior authorization form to CVS Caremark toll-free at 1-866-237-5512 and include the required supporting documentation as specified per indication.
Attach supporting documentation for positive response or diagnosis
For continuation requests attach documentation of beneficial clinical response (e.g., chart notes or medical record). For initial therapy attach documentation supporting the diagnosis; if genetic testing is unavailable or no mutation identified, submit chart notes/medical record. For DIRA, if IL1RN mutation is present, attach documentation of mutation status.
Prior therapy documentation for recurrent pericarditis
For recurrent pericarditis initial therapy requests, attach chart notes, medical record documentation, or claims history showing failure of at least two agents of standard therapy (e.g., colchicine, NSAIDs, corticosteroids) when applicable.
Provider specialty requirement
Prescriptions must be by or in consultation with an appropriate specialist: rheumatologist or immunologist for CAPS and DIRA; cardiologist, rheumatologist, or immunologist for recurrent pericarditis.
TB screening documentation
Document TB test results (e.g., TST or IGRA) within 6 months of initiating therapy. If positive, document TB treatment status (latent TB treatment initiated, completed, not initiated, or active TB).
Incomplete documentation risk
Approval may be denied or delayed if required supporting documentation (diagnosis confirmation, genetic testing, response documentation, prior therapy history) is not provided.
Background
This prior authorization request form is administered by CVS Caremark for HMSA commercial benefit plans and notes that approvals may be subject to dosing limits per FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines. The form collects patient demographics (including weight and height), where the drug will be dispensed and administered, and asks for the ICD-10 diagnostic code.
The form includes a general screening section for biologic/targeted synthetic drug use and TB screening: it asks whether the patient has ever received a biologic/targeted synthetic agent, whether a TB test (e.g., TST, IGRA) was performed within 6 months of initiating therapy, the TB test result (positive/negative/unknown), and TB management status (latent treated/initiated/not initiated or active TB).
Diagnosis-specific branches collect indication-specific criteria and required documentation for CAPS (including FCAS and MWS), DIRA, and recurrent pericarditis. The form requires provider specialty confirmation (e.g., rheumatologist or immunologist for CAPS and DIRA; cardiologist, rheumatologist, or immunologist for recurrent pericarditis), age and weight thresholds where applicable (e.g., 12 years age threshold and 10 kg or more weight threshold), prior therapy and response documentation, and genetic testing documentation for IL1RN mutation status when relevant.
Required documentation attachments include chart notes, medical records, genetic test results, or claims history to support diagnosis, prior therapies, and evidence of clinical response. The form instructs providers to fax the completed HMSA prior authorization form to CVS Caremark toll-free at 1-866-237-5512 with the required supporting documentation.
PAP: Patient assistance program (manufacturer-provided assistance).
TST: Tuberculosis skin test.
IGRA: Interferon-gamma release assay (TB test).
IL1RN: Interleukin-1 receptor antagonist gene; mutation status relevant to DIRA.
Revision History
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