CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSACOM - Prior Authorization Request

A payer/provider prior authorization request form used by CVS Caremark (for HMSA members) to collect clinical and administrative information to determine coverage for specialty biologic/targeted therapies (e.g., Tremfya) across multiple indications (plaque psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis). It governs required clinical questions, diagnosis, site of administration, TB screening, prior therapy and continuation criteria, and submission/fax/contact instructions.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSACOM - Prior Authorization Request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax completed form to CVS Caremark Specialty Programs at 1-866-237-5512 to request prior authorization; approvals may be subject to dosing limits per labeling/compendia/guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form continues to collect prior authorization information and clinical documentation for specialty biologic/targeted therapies.

5Indications covered on form

2Product options listed

12TB screening window (months)

Prior Authorization Request Form — Summary

This document is a CVS Caremark Specialty prior authorization request form used for HMSA members to collect clinical and administrative information needed to determine coverage for specialty biologic and targeted synthetic therapies, including products such as Tremfya IV and Tremfya SQ.

The form routes questions by primary indication (e.g., plaque psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis) to capture indication-specific initiation and continuation criteria, prior therapy history and response, and safety screening (for example, tuberculosis testing and status).

Providers must supply demographic and prescriber information, indicate the ICD-10 diagnosis code, and identify dispensing and administration sites to support benefit and administration determinations.

To submit, fax the completed form to CVS Caremark Specialty Programs at 1-866-237-5512; contact numbers for prior authorization or specialty customer care are provided on the form. Approvals may be subject to dosing limits per labeling, compendia, or evidence-based guidelines.

Coverage stance: informational. Status: CURRENT.

Indications covered on form5

Product options listed2 (Tremfya IV, Tremfya SQ)

TB screening window (months)1 (within 12 months)

PayerHawaii Medical Service Association (HMSA)

Policy titlePrior Authorization Request Form (CVS Caremark Specialty)

Policy numberN/A

Effective date

Submission, Documentation, and Billing Requirements

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512 to request prior authorization. Note that approvals may be subject to dosing limits in accordance with FDA‑approved labeling, accepted compendia, and/or evidence‑based practice guidelines.

Documentation Required

Document clinical evidence of response or prior therapies

Attest that documentation supporting clinical responses, prior biologic or conventional therapy use, TB testing and treatment status, and reasons to avoid therapies is available for review if requested by CVS Caremark or the benefit plan sponsor.

Billing Rule

Indicate site of dispensing and administration

Indicate where the drug will be dispensed and where it will be administered (select the appropriate site options on the form) to support determination of benefit and administration.

Denial Risk

Potential denial if criteria not met or documentation unavailable

Requests that do not include required clinical answers (for example, diagnosis, prior therapy history, TB screening) or lack supporting documentation may be denied or not authorized.

Definitions and Thresholds Referenced by the Form

Thresholds and Definitions

BSA categories< 3%; >= 3% to < 10%; >= 10%

TB test recencyTest performed within 12 months of initiating therapy

Definition: BSABody Surface Area

Definition: TBTuberculosis

Definition: CRPC-reactive protein

This specialty prior authorization request form is administered by CVS Caremark for HMSA members and is used to determine coverage for certain medications by collecting the most accurate diagnosis and necessary clinical details.

The form routes questions by indication and captures prior biologic or targeted synthetic therapy use, clinical response measures, and safety screening such as tuberculosis testing within 12 months of initiating therapy.

Providers are instructed to fax the completed form to CVS Caremark at 1-866-237-5512 and to provide documentation supporting prior therapies, clinical response, and TB testing/treatment status if requested.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSACOM - Prior Authorization Request

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax completed form to CVS Caremark Specialty Programs at 1-866-237-5512 to request prior authorization; approvals may be subject to dosing limits per labeling/compendia/guidelines.

SourceLink

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HMSACOM - Prior Authorization Request

Prior Authorization Request Form — Summary

Criteria and Routing Questions on the Form

Code Entry Options on the Form

Submission, Documentation, and Billing Requirements

Definitions and Thresholds Referenced by the Form

Document Changes and Review Dates

Tremfya IV	Product selection option on form
Tremfya SQ	Product selection option on form