CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSACOM - Prior Authorization Request

Form and workflow for requesting prior authorization from CVS Caremark for specialty prescription medications administered or dispensed for HMSA members, including exception criteria, diagnosis-specific question flows, preferred product substitution, and documentation requirements.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSACOM - Prior Authorization Request

Policy CodePolicy N/A

Change TypeOperational form/update (no material coverage change)

Effective Date

Next Review Date

Key ActionProviders must complete and fax the HMSACOM Prior Authorization Request to CVS Caremark at 1-866-237-5512 and submit supporting documentation when failures/intolerance/contraindications to preferred products are indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this document is an operational prior authorization form and workflow; no policy changes to clinical coverage were reported.

7Indications listed

~20Preferred products

MultipleDiagnosis branches

Policy overview & scope

This is the CVS Caremark HMSACOM Prior Authorization Request form used to request coverage for specialty medications for HMSA members. The form is administered by CVS Caremark and must be faxed to CVS Caremark at 1-866-237-5512; questions may be directed to CVS Caremark at 1-808-254-4414.

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The form collects clinical, demographic, and prescriber information needed to adjudicate prior authorization (PA) requests, including patient identifiers and contact details, diagnosis and ICD-10 code, weight/height, site of dispensing/administration, and prescriber name, specialty, NPI and office contact information.

Its purpose is to operationalize exception criteria and preferred product substitution across multiple immune-mediated inflammatory disease indications (e.g., ankylosing spondylitis, Crohn's disease, plaque psoriasis, psoriatic arthritis, rheumatoid arthritis, ulcerative colitis) and to document required supporting information (such as prior therapy failures, intolerance or contraindications, continuation-of-therapy response, and tuberculosis testing) to determine PA eligibility.

Authorization criteria and question flow

Exception Criteria Questions - Adult Indication Check

Determine if product is being requested for an adult (≥18) with listed indications.

Adult indication check: Patient is an ADULT (18 years of age or older) with one of: Ankylosing spondylitis, Crohn's disease, Plaque psoriasis, Psoriatic arthritis, Rheumatoid arthritis, Ulcerative colitis

If Yes -> proceed to Question B; if No -> skip to Criteria Questions

Preferred Product Substitution

Ask whether treatment can be switched to a preferred product for the indicated condition.

Preferred product substitution

Preferred products list: List of preferred products provided by indication (see code_groups for product list).

Continuation of Therapy / Sample Assistance

Questions to determine if request is continuation and whether patient is receiving samples or manufacturer's assistance.

Continuation and sample assistance

Continuation details: If Yes -> Is patient currently receiving product through samples or manufacturer's patient assistance program? If unknown answer 'Yes'.
If Yes -> continue to next step; If No -> skip to Criteria Questions
Not continuation: If No -> skip to Criteria Questions

General Criteria Questions (TB and combination therapy)

Assess concomitant biologic use and TB risk prior to authorization.

TB and combination therapy

Combination biologic question: Will the requested drug be used in combination with any other biologic or targeted synthetic for the same indication?
Asked and recorded; proceed to next question
Prior biologic/TB history: Has the patient ever received a biologic or targeted synthetic associated with increased TB risk? If Yes -> Continue to TB follow-up questions.
TB testing within 12 months: Has the patient had a tuberculosis (TB) test (TST or IGRA) within 12 months of initiating therapy?
If TB test positive determine latent vs active and treatment status per form

Plaque Psoriasis Specific Additional Criteria

Criteria for moderate to severe disease, prescriber specialty, continuation response and prior therapy for plaque psoriasis.

Plaque psoriasis - general criteria

Moderate to severe disease: Is the patient diagnosed with moderate to severe plaque psoriasis?
Adult check: Is the patient an adult?
Prescriber specialty: Is the requested drug prescribed by or in consultation with a dermatologist?
Continuation of therapy: If continuation: document samples/manufacturer assistance (Unknown treated as Continue to #108); confirm positive clinical response (low disease activity or improvement), reduction in BSA from baseline or improvement in signs/symptoms to allow no further questions if achieved.

Preferred products (listed on form)

Preferred products listed by indication (drug names as provided on form)mixed

adalimumab-adaz	preferred product (multiple indications)
Avsola	preferred product (multiple indications)
Cosentyx IV/SQ	preferred product (ankylosing spondylitis, plaque psoriasis)
Enbrel	preferred product (multiple indications)
Hadlima	preferred product (multiple indications)
Hyrimoz (Cordavis brand)	preferred product (multiple indications)
Inflectra	preferred product (multiple indications)
Rinvoq	preferred product (multiple indications)
Simponi Aria	preferred product (multiple indications)
Taltz	preferred product (ankylosing spondylitis, plaque psoriasis)

1–10 of 19

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What providers must do

Prior Authorization

Submit prior authorization via fax

Complete and fax the HMSACOM Prior Authorization Request to CVS Caremark as instructed on the form. Use the fax number for submissions and the contact number for questions.

Fax: 1-866-237-5512
Contact: 1-808-254-4414

Documentation Required

Submit supporting documentation for failures/intolerance/contraindications

When the form indicates the patient has documented inadequate response, intolerable adverse event, or contraindication to ALL preferred products for the relevant indication (self-administered or not), submit supporting clinical documentation as requested. This requirement is indicated in each diagnosis-specific branch (e.g., Ankylosing spondylitis, Crohn's disease, Plaque psoriasis, Psoriatic arthritis, Rheumatoid arthritis, Ulcerative colitis).

Documentation Required

TB testing documentation

Document tuberculosis testing status as part of the PA: indicate whether a TB test (TST or IGRA) was performed within 12 months of initiating therapy and report the test result. If positive, document whether the patient has latent or active TB and the treatment status for latent TB (initiated, completed, or not initiated).

Document TST or IGRA within 12 months
If positive, indicate latent vs active TB
If latent TB, indicate treatment status: initiated, completed, or not initiated

Documentation Required

Clinical response documentation for continuation

For continuation requests, document a positive clinical response since starting the requested drug. Acceptable evidence includes documentation of low disease activity, reduction in body surface area (BSA) affected from baseline, or improvement in signs and symptoms (for example: decreased itching, redness, flaking, scaling, burning, cracking, pain).

Low disease activity or overall clinical improvement
Reduction in BSA affected from baseline
Improvement in signs/symptoms (e.g., itching, redness, flaking, scaling, burning, cracking, pain)

Billing Rule

Preferred product substitution process

If the patient can be switched to a listed preferred product for the indicated condition, obtain and submit the prior authorization form specific to that preferred product instead of proceeding with this request.

If Yes: obtain and submit PA form for the preferred product listed for the indication

Definitions

Self-administered: Medication administered orally or by self-injection, as asked on the form.

Preferred product: Products listed by CVS Caremark for which coverage is provided and which are the preferred alternatives for each indicated condition (the form provides indication-specific lists of preferred products).

Document changes and review dates

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSACOM - Prior Authorization Request

Policy CodePolicy N/A

Change TypeOperational form/update (no material coverage change)

Effective Date

Next Review Date

SourceLink

On This Page

If Unknown for samples/assistance treat as Yes (Continue to #108).

Prior biologic exposure: Has patient ever received or currently receiving a biologic/targeted synthetic for moderate to severe plaque psoriasis (excluding samples/assistance)? If Yes -> No further questions.

Prior therapy requirements: Assess crucial body areas, BSA thresholds (<3%, 3–<10%, ≥10%), inadequate response/intolerance to phototherapy or methotrexate/cyclosporine/acitretin, or clinical reasons to avoid these agents (alcohol use disorder, liver disease, drug interaction, pregnancy/planning, breastfeeding, significant comorbidity, hypersensitivity, history of intolerance, other).

If any specified condition met -> No Further Questions per form.