CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior Authorization for Multiple Sclerosis Disease-Modifying Therapies (CVS Caremark PA Form)

Form and criteria governing prior authorization requests to CVS Caremark for coverage of disease-modifying therapies for multiple sclerosis for HMSA members; applies to prescribing clinicians submitting PA for MS drugs.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization for Multiple Sclerosis Disease-Modifying Therapies (CVS Caremark PA Form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form and supporting documentation to CVS Caremark via fax to 1-866-237-5512.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form used for prior authorization

3MS diagnosis options on form

2Ocrevus product options

Coverage Criteria and Form Attestations

PA intake and attestation criteria

Form-based screening and attestation questions to support coverage decisions; approvals may be subject to dosing limits per labeling.

PA intake questions: Provider must indicate diagnosis (relapsing form of multiple sclerosis, clinically isolated syndrome of multiple sclerosis, primary progressive multiple sclerosis, or other).

Continue to subsequent questions per form flow.

Concurrent therapy query: Does the patient will be taking the requested drug with any other disease-modifying multiple sclerosis (MS) agent? (Note: Ampyra and Nuedexta are not disease modifying).

Answer Yes or No; continue to next question.

Prescriber specialty: Will the requested drug be prescribed by or in consultation with a neurologist?

Answer Yes or No; continue to next question.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization for Multiple Sclerosis Disease-Modifying Therapies (CVS Caremark PA Form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form and supporting documentation to CVS Caremark via fax to 1-866-237-5512.

SourceLink

On This Page

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Patient age category must be indicated: less than 18 years of age or greater than or equal to 18 years of age.

If <18, prescriber must complete pediatric risk/benefit attestation.

Pediatric attestation (if applicable): For patients <18 years of age, prescriber must attest that they have evaluated the risks and benefits of treatment and that benefits outweigh risks.

Answer Yes or No; continue to next question.

Continuation of therapy: Indicate whether this is a request for continuation of therapy (Yes or No).

If No, proceed to drug selection; if Yes, proceed to assessment of disease status while on therapy.

Requested drug (if new request): Select the requested product: Ocrevus or Ocrevus Zunovo.

No further questions after selecting product for new requests.

Disease status (if continuation): For continuation requests, indicate whether the patient is experiencing disease stability or improvement while receiving the requested drug (Yes or No).

No further questions after indicating disease status for continuation requests.

Attestation: Prescriber or authorized signer must attest that the information is accurate and that supporting documentation is available for review by CVS Caremark or the benefit plan sponsor.

Signature and date required on the form.

The PA form itself does not list discrete coverage criteria on the face of the form. Instead, it functions as an intake and attestation document used by CVS Caremark to collect the clinical information needed to evaluate coverage for disease‑modifying therapies for multiple sclerosis; approvals may be subject to dosing limits consistent with labeling and benefit plan rules.

The form does not enumerate explicit Not Medically Necessary conditions. Coverage determinations regarding medical necessity are made during the prior authorization review process and are governed by the member’s benefit plan and any applicable clinical guidance; providers must submit the completed PA form and supporting documentation for review.

Diagnosis and Procedure Coding

Requested diagnosis codeICD-10

ICD-10

What is the ICD-10 code? (field on form)

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required. Submit a completed prior authorization form to CVS Caremark via fax to 1-866-237-5512. If you have questions regarding the prior authorization process, contact CVS Caremark at 1-808-254-4414. For patient eligibility, copay, or medication delivery inquiries, contact the CaremarkConnect Specialty Customer Care Team at 1-800-237-2767.

Fax completed PA form to CVS Caremark: 1-866-237-5512
PA questions: CVS Caremark 1-808-254-4414
Specialty Customer Care (eligibility/cost/delivery): CaremarkConnect 1-800-237-2767

Note

Concurrent DMT Query

The PA form asks whether the requested medication will be taken with another disease-modifying multiple sclerosis (DMT) agent and captures the intent for concurrent therapy. Answer the question on concurrent DMT use accurately on the form (Yes/No) to ensure appropriate review.

Question on form: "Will the patient be taking the requested drug with any other disease modifying multiple sclerosis (MS) agent?"
Note: Ampyra and Nuedexta are not disease-modifying agents

Documentation Required

Required Documentation and Attestations

Provide complete and accurate documentation and attestations. The prescriber must include the correct diagnosis, patient demographics, ICD-10 code where applicable, and sign the attestation that the information is accurate and that supporting documentation is available upon request.

Include patient name, ID, date of birth, and contact information on the PA form
Provide prescriber name, specialty, NPI, office phone and fax
Record the specific diagnosis (select applicable MS type) and any relevant ICD-10 code
Prescriber or authorized signature and date required
Attestation required: "I attest that this information is accurate and true, and that documentation supporting this information is available for review if requested by CVS Caremark or the benefit plan sponsor."

Denial Risk

Coverage Contingent on Prior Authorization

Coverage for the requested medication is contingent on prior authorization. Failure to submit the required PA to CVS Caremark may result in denial of drug coverage in accordance with the patient's benefit plan.

Approvals may be subject to dosing limits consistent with FDA labeling, accepted compendia, and evidence-based guidelines
If PA is not received or is incomplete, the claim may be denied per the member's benefit plan

Background and Policy Use

This prior authorization request form is used to obtain authorization for disease‑modifying therapies for multiple sclerosis. It collects the patient and prescriber demographics, the most accurate diagnosis for the prescribed medication, and supporting attestations so CVS Caremark can make an appropriate coverage determination distinguishing relapsing forms and other MS presentations. Providers should fax the completed form to CVS Caremark at 1-866-237-5512 for review.

Key Definitions

Relapsing form of multiple sclerosis — definition and form context

DefinitionRelapsing form of multiple sclerosis — includes relapsing‑remitting and secondary progressive disease for those who continue to experience relapse.

Form navigationWhen selected on the PA form, continue to question #2.

Related diagnoses on formForm also lists: Clinically isolated syndrome of multiple sclerosis; Primary progressive multiple sclerosis; Other (all direct attendees continue to #2).