CurrentHawaii Medical Service Association (HMSA)Policy N/A

Oncology Global PA - HMSA

This document is a prior authorization request form used by HMSA/CVS Caremark for oncology medications; it collects patient, prescriber, regimen, diagnosis and clinical benefit information to support coverage determination and documents fax submission instructions and contact numbers.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyOncology Global PA - HMSA

Policy CodePolicy N/A

Change Typeclarified (no material clinical changes)

Effective Date

Next Review Date

Key ActionFax the completed Oncology Global PA form and supporting documentation to CVS Caremark Specialty Programs at 1-866-237-5512 for prior authorization determination.

SourceLink

POLICY UPDATE CHANGES

Form footer indicates 'Global Oncology HMSA - 10/2022'.

1-866-237-5512PA Submission Fax

1-808-254-4414PA Inquiry Phone

1-800-237-2767Specialty Customer Care

Oncology Global Prior Authorization Form — Overview

This is an administrative prior authorization request form used by HMSA/CVS Caremark to collect necessary patient, prescriber, regimen, diagnosis and clinical benefit information to support coverage determinations for oncology medications. The form requests patient identifiers, prescriber identifiers, demographic/administrative data, regimen details, ICD-10 diagnosis code and supportive documentation, and prescriber attestation signature.

Form Completion / Authorization Determination Inputs

Information requested to determine prior authorization:

ALL of the following

Provide patient identifiers: name, ID, date of birth, phone number
Provide prescriber identifiers: name, specialty, NPI, office telephone, office fax
Provide demographic/administrative data: patient weight (kg), height (optional), site of dispensing (select one)
Provide administration site (select one)
List or describe all agents in the oncology regimen and indicate whether single agent or multiple agents
Provide patient diagnosis and ICD-10 code and attach relevant supportive data
Action Required: Please attach relevant and supportive data of patient's diagnosis.
If regimen previously authorized
- Indicate whether the single agent or entire drug regimen was previously authorized by HMSA/CVS for this member: Yes / No / Unknown
- If No or Unknown, no further questions
  per form
If previously authorized = Yes
- Provide evidence of clinical benefit (e.g., positive clinical response, lack of disease progression) and attach current clinical documentation (office notes, studies)
  Action required: Please attach current clinical documentation (e.g., office visit notes and applicable studies)
- If evidence of benefit = No, no further questions
  per form
Indicate whether the requested medication/regimen is for an FDA-approved indication or an indication supported by NCCN with I or IIA recommendation (Yes/No)
Indicate whether the patient has a contraindication to the requested medication(s) as listed in prescribing information (Yes/No)
Prescriber attestation signature and date confirming accuracy and availability of supporting documentation

Required Provider Actions and Submission Instructions

Prior Authorization

Submit completed prior authorization form

Fax the completed Oncology Global PA form and all supporting documentation to CVS Caremark Specialty Programs for prior authorization determination.

Fax: 1-866-237-5512

Documentation Required

Attach diagnosis and clinical documentation

Attach relevant and supportive data of the patient's diagnosis including the ICD-10 diagnosis code and, when applicable, current clinical documentation demonstrating benefit (office visit notes, studies) per the form instructions.

Documentation Required

Prescriber attestation

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

Billing Rule

Contact numbers for inquiries

For prior authorization questions contact CVS Caremark; for patient eligibility, copay, or medication delivery inquiries contact Specialty Customer Care. Opt-out and fax consent instructions are provided on the form.

PA questions: 1-808-254-4414
Specialty Customer Care: 1-800-237-2767

Definitions

Opt-out request: mechanism by which the recipient can request not to receive telemarketing fax transmissions from CVS Caremark. The recipient may call the toll-free number 877-265-2711 or send an opt-out request via email to do_not_call@cvscaremark.com. An opt-out request is only valid if it identifies the number to which the request relates and will be honored within thirty days of receipt, provided the requester does not subsequently give express permission to receive facsimile advertisements at that number.