CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior Authorization Request (CVS Caremark-administered) for Specialty Medications for Gaucher Disease

A prior authorization request form used by HMSA Medicare Advantage (administered by CVS Caremark) to request coverage for a specialty medication for Gaucher disease; collects patient/provider data, diagnosis (ICD-10), disease type, confirmation testing, and continuity/benefit questions. It governs prior authorization submission and documentation requirements for coverage determination.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request (CVS Caremark-administered) for Specialty Medications for Gaucher Disease

Policy CodePolicy N/A

Change TypeAdministrative/form content; clarified contact and opt-out instructions

Effective Date

Next Review Date

Key ActionFax the completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512 and include patient, prescriber, site of care, ICD-10 diagnosis, disease type, and answers to criteria questions.

POLICY UPDATE CHANGES

Form updated with CVS Caremark contact numbers and opt-out fax instructions; includes Cerezyme HMSAMED C26856-A - 01/2024 identifier.

1Primary Indication Covered (Gaucher disease)

1Required Diagnostic Confirmation

1Submitting Payer Contact (CVS Caremark fax)

Coverage Summary

This document is a prior authorization request form for HMSA Medicare Advantage where CVS Caremark administers the prescription benefit. Scope: it is used to request coverage for a specialty medication for Gaucher disease and collects patient/provider data, ICD-10 diagnosis, disease type, confirmation testing, and continuity/benefit questions. Coverage stance: covered_with_criteria. Subject: Prior authorization form for CVS Caremark-administered prescription (Cerezyme/Gaucher disease). Status: CURRENT. Note: This is a CVS Caremark‑administered prior authorization form for Cerezyme/Gaucher disease under HMSA Medicare Advantage (form identifier Cerezyme HMSAMED C26856-A - 01/2024) and includes fax/submission instructions to CVS Caremark for review.

Key metadata

PayerHMSA (Medicare Advantage) - prescription benefit administered by CVS Caremark

Policy subjectPrior authorization form for CVS Caremark-administered prescription (Cerezyme/Gaucher disease)

Coverage stanceCovered with criteria (form-driven prior authorization)

StatusCURRENT

Last review date2024-01-01

Primary requirementsDiagnostic confirmation required for initial therapy: enzyme assay showing beta-glucocerebrosidase deficiency OR genetic testing; results must be available upon request

Eligibility and Documentation Criteria

Eligibility and Documentation Criteria for Coverage Determination

Form-driven criteria used by CVS Caremark to determine prior authorization approval:

ALL of the following

Patient and prescriber identification: Patient identification and demographics provided (name, ID, DOB, phone)
Prescriber information: Prescriber identification provided (name, specialty, NPI, office phone/fax, signature and date)
Site of care: Site of dispensing and site of administration indicated
Diagnosis code: ICD-10 code for the diagnosis provided
Diagnosis selection
- Gaucher disease (continue to type selection and subsequent questions)
- Other diagnosis (no further questions on this form)
If Gaucher disease, disease type
- Type 1 (continue to treatment questions)
- Type 2 (continue to treatment questions)
- Type 3 (continue to treatment questions)
- Other type: Other (continue to treatment questions)
Current therapy status branching
- If patient currently receiving requested drug
  - Continuation benefit question: Patient is receiving benefit from therapy (defined as not experiencing inadequate response or intolerable adverse events) -> No further questions
    Benefit from therapy defined on form
  - Continuation - no benefit: Patient is not receiving benefit from therapy -> No further questions
- If patient not currently receiving requested drug (Initial therapy): Answer initial therapy questions starting at #10
  Diagnosis confirmation required by enzyme assay demonstrating deficiency of beta-glucocerebrosidase OR genetic testing; supporting results must be available upon request
Prescriber attestation that documentation is accurate and available upon request (signature/date required)

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Actions Required of Providers

Prior Authorization

Submit prior authorization form to CVS Caremark

Fax the completed prior authorization form to CVS Caremark Specialty Programs for review. Use the toll-free fax number 1-866-237-5512. Include patient identifiers and contact, prescriber information, site of care/site of administration, the ICD-10 diagnosis code, the Gaucher disease type selection, and answers to the form’s criteria questions.

Fax number: 1-866-237-5512
Required form fields: patient name, patient ID, date of birth, patient phone
Prescriber fields: physician name, specialty, NPI, office phone, office fax
Site of care/site of administration (as indicated on form)
ICD-10 diagnosis code entry
Disease type selection (Type 1, Type 2, Type 3, Other)
Answers to the criteria questions on the form

Documentation Required

Provide diagnostic confirmation on request

For initial therapy requests, documentation confirming the Gaucher disease diagnosis must be available upon request. Confirmation requires either an enzyme assay demonstrating deficiency of beta-glucocerebrosidase (glucosidase) enzyme activity OR genetic testing results supporting the diagnosis.

Acceptable diagnostic confirmation: beta-glucocerebrosidase enzyme assay showing deficiency OR genetic testing
Supporting test results must be available upon request

Documentation Required

Prescriber attestation required

The prescriber or an authorized signer must sign and date the form attesting that the information provided is accurate and that supporting documentation is available for review if requested by CVS Caremark or the benefit plan sponsor.

Prescriber or authorized signature required
Date (mm/dd/yy) required
Attestation: information is accurate and supporting documentation is available for review

Billing Rule

Benefit plan prior authorization requirement

This patient’s benefit plan requires prior authorization for certain medications. Approvals may be subject to dosing limits consistent with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.

Prior authorization required by benefit plan
Approvals may include dosing limits per FDA labeling, compendia, and evidence-based guidelines

Background

Background: This prior authorization request form is used by HMSA Medicare Advantage and administered by CVS Caremark to collect the clinical and administrative information necessary to determine coverage for specialty medications for Gaucher disease. The form gathers patient identification and demographics, prescriber information, site of dispensing and administration, and the ICD-10 code for the diagnosis. It guides submission via fax to CVS Caremark Specialty Programs at 1-866-237-5512 and provides contact numbers for CVS Caremark for questions.

Benefit from therapy: defined on the form as not experiencing an inadequate response or any intolerable adverse events from therapy.