CurrentHawaii Medical Service Association (HMSA)Policy N/A

QUEST Fax Form

Prior authorization request form administered by CVS Caremark for infliximab and its biosimilars for multiple indications (Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, Behcet's disease, hidradenitis suppurativa, pyoderma gangrenosum, sarcoidosis, Takayasu's arteritis, uveitis, reactive arthritis, immune checkpoint inhibitor-related toxicities, acute GVHD). It collects patient/provider demographics, site of care, ICD-10 code, specific indication screening questions, prior therapy and continuation criteria, tuberculosis screening, and dosing path branching.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyQUEST Fax Form

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Form collects branching criteria and specialist/prior therapy requirements for infliximab and biosimilars across multiple indications.

17Listed clinical indications (selectable)

6Pediatric age threshold present

MultipleBiosimilars listed

Diagnoses listed on dosing question 990

2Prescribed product branching items (991/993)

Coverage Summary

This is a CVS Caremark prior authorization fax form for infliximab (Remicade) and listed infliximab biosimilars (Avsola, Inflectra, Renflexis, Zymfentra, unbranded infliximab) used across multiple indications including Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing/non-radiographic axial spondyloarthritis, psoriatic arthritis, plaque psoriasis, Behcet's disease, hidradenitis suppurativa, pyoderma gangrenosum, sarcoidosis, Takayasu's arteritis, uveitis, reactive arthritis, immune checkpoint inhibitor-related toxicities, and acute graft-versus-host disease. The form collects patient and provider demographics and site-of-care details, requests an ICD-10 code entry, and uses branching indication-specific screening questions that include TB screening and results, specialist involvement, prior biologic/targeted-synthetic and conventional therapy history, and measures of clinical response for continuation requests. Coverage stance: covered_with_criteria.

Key thresholds

Age pediatric cutoff>= 6 years for Crohn's disease and ulcerative colitis

Methotrexate trial (RA)>= 3 months at >= 15 mg/week

Hidradenitis suppurative antibiotic trial>= 90 days of oral antibiotic therapy

BSA branching ranges (plaque psoriasis)>= 3% to < 10%; >= 10%

RA improvement threshold>= 20% improvement from baseline in tender/swollen joint count, pain, or disability

Initial Therapy Criteria (by indication)

Initial therapy criteria for specified indications. Covered when ALL of the following indication-specific requirements are met per branch logic.

ANY of the following

Crohn's disease - Initial therapy
- Patient has a diagnosis of moderately to severely active Crohn's disease (CD).
- Patient is 6 years of age or older.
  Age requirement applies to initial therapy
- Requested drug is prescribed by or in consultation with a gastroenterologist.

Continuation Therapy Criteria (by indication)

Continuation-of-therapy branches by indication

Crohn's disease - Continuation of therapy

Baseline requirements: Diagnosis of moderately to severely active Crohn's disease; age >=6; prescribed by or in consultation with a gastroenterologist
Questions 100-103
Response assessment
- Improvement measures: Improvement in at least one: abdominal pain/tenderness, diarrhea, body weight, abdominal mass, hematocrit, mucosal appearance on endoscopy/CTE/MRE/intestinal ultrasound, improvement on disease activity scoring tool (e.g., CDAI)
  Question 106

Ulcerative colitis - Continuation of therapy

General Screening and Branching Logic

General initial branching and TB screening

Combination use question: Will the requested drug be used in combination with any other biologic or targeted synthetic drug?

Question 1; Yes/No (both continue to #2)

Prior biologic TB-risk question: Has the patient ever received a biologic or targeted synthetic drug associated with increased TB risk?

Question 2; Yes -> Continue to #9; No -> Continue to #3

TB test within 12 months requirement: Has the patient had a TB test (TST or IGRA) within 12 months of initiating therapy?

Question 3; Yes/No both continue to #4

TB test result branching

Provider Actions & Prior Authorization Steps

Prior Authorization

Fax completed prior authorization form to CVS Caremark

Fax completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512 for prior authorization determination. For questions regarding the prior authorization, contact CVS Caremark at 1-808-254-4414. For specialty customer care (eligibility, copay, delivery) contact CaremarkConnect at 1-800-237-2767.

Fax the completed prior authorization form to CVS Caremark Specialty Programs: 1-866-237-5512
For PA questions: 1-808-254-4414
For specialty customer care (eligibility, copay, delivery): CaremarkConnect 1-800-237-2767

Documentation Required

Document TB screening and results

Indicate whether TB testing (e.g., TST or IGRA) was performed within 12 months of initiating therapy and record the test result (positive, negative, or unknown). If positive, document whether the patient has latent or active TB and the treatment status (treatment initiated, completed, or not initiated).

Applicable Codes

Indication / diagnosis code entry (ICD-10)ICD-10

ICD-10 code to be entered by provider (blank field on form)

Drug names listed on formmixed

Remicade	Brand name infliximab listed as selectable drug
unbranded infliximab	Generic/infliximab
Inflectra	Infliximab biosimilar
Renflexis	Infliximab biosimilar
Avsola	Infliximab biosimilar
Zymfentra	Infliximab biosimilar

Background

This prior authorization fax form is administered by CVS Caremark on behalf of HMSA to collect the patient and clinical information necessary to authorize infliximab or infliximab biosimilars for multiple inflammatory and autoimmune indications. The document captures TB screening (testing within 12 months and test result options), documents specialist involvement and NPI, records prior biologic/targeted synthetic and conventional therapy use or reasons to avoid therapies, and requests evidence of clinical response for continuation requests (specific improvement measures are listed per indication).

Definitions / Abbreviations

CDAICrohn's Disease Activity Index

UCEISUlcerative Colitis Endoscopic Index of Severity

Clinical Evidence

No clinical trial or literature citations are included on the form; the form captures clinical response measures and real-world response items for continuation requests but does not provide trial or evidence citations. Leave the clinical evidence section empty (or link to the evidence section) only if the source document provided trial references — this form does not.

Revision History

2026-04clarifiedLatest

Form collects branching criteria and specialist/prior therapy requirements for infliximab and biosimilars across multiple indications. Document footer indicates 'Infliximab HMSAMCD C12996-A -04/2026.'

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyQUEST Fax Form

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review Date

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

SourceLink

On This Page

This request is for initial therapy (not continuation).

If request is for continuation, evaluate under continuation criteria (#103-106).

Prior therapy and response requirements

Documented prior inadequate response, intolerance, contraindication, or inability to use conventional therapy (e.g., corticosteroids, immunomodulators such as azathioprine/6-MP, methotrexate) when clinically appropriate.
If applicable, documentation of prior biologic therapy and reason for discontinuation (e.g., lack of efficacy, loss of response, adverse event).

Ulcerative colitis - Initial therapy

Patient has a diagnosis of moderately to severely active ulcerative colitis (UC).
Patient is 6 years of age or older.
Age requirement applies to initial therapy
Requested drug is prescribed by or in consultation with a gastroenterologist.
This request is for initial therapy (not continuation).
If request is for continuation, evaluate under continuation criteria (#203-206).
Prior therapy and response requirements
- Documented prior inadequate response, intolerance, contraindication, or inability to use conventional therapy (e.g., aminosalicylates, corticosteroids, immunomodulators when appropriate).
- If applicable, documentation of prior biologic therapy and reason for discontinuation (e.g., lack of efficacy, loss of response, adverse event).

Rheumatoid arthritis - Initial therapy

Patient has a diagnosis of moderately to severely active rheumatoid arthritis (RA).
Patient is an adult.
Pediatric RA handled separately
Requested drug is prescribed by or in consultation with a rheumatologist.
This request is for initial therapy (not continuation).
If request is for continuation, evaluate under continuation criteria (#303-306).
Prior treatment and combination requirements
- Documented trial and inadequate response, intolerance, or contraindication to at least one conventional synthetic DMARD (e.g., methotrexate) unless there is a documented clinical reason not to use (e.g., pregnancy, liver disease, drug interaction, hypersensitivity).
- If the product labeling or clinical guidance recommends combination with methotrexate or leflunomide, either the patient is receiving combination therapy or a documented clinical reason to avoid methotrexate/leflunomide is provided (examples: alcohol use disorder, significant liver disease, drug interaction, pregnancy/planning pregnancy, breastfeeding, other contraindication).
- If the patient has previously received a biologic or targeted synthetic DMARD for RA (excluding samples or assistance program supply), document prior agent and reason for discontinuation/failure; prior biologic use does not automatically preclude initial coverage but must be documented.

Hidradenitis suppurativa - Initial therapy

Patient has a diagnosis of moderate to severe hidradenitis suppurativa (HS).
Requested drug is prescribed by or in consultation with a dermatologist or a specialist experienced in HS management.
This request is for initial therapy (not continuation).
Prior therapy requirements
- Documented inadequate response, intolerance, or contraindication to adequate trials of conventional therapies (e.g., topical and systemic antibiotics, intralesional corticosteroids, antiseptic washes, hormonal therapies if appropriate).
- Documentation of disease severity (e.g., lesion count, Hurley stage, impact on function/quality of life) to support moderate-to-severe classification.

Immune checkpoint inhibitor-related toxicity and inflammatory arthritis - Initial therapy

Patient has a confirmed diagnosis of immune checkpoint inhibitor (ICI)-related toxicity or ICI-related inflammatory arthritis attributed to immune checkpoint inhibitor therapy.
Requested drug is prescribed by or in consultation with an appropriate specialist (e.g., oncologist, rheumatologist, or other relevant specialist).
This request is for initial therapy (not continuation).
Prior therapy and severity documentation
- Documentation that ICI-related toxicity/inflammatory arthritis is of sufficient severity to warrant initiation of biologic therapy, including failure, intolerance, or contraindication to standard initial management (e.g., corticosteroids, NSAIDs, disease-specific conservative measures) when clinically appropriate.
- Document baseline and prior treatments for the ICI-toxicity, including corticosteroid use and response, and rationale for escalation to the requested agent.

Baseline requirements: Diagnosis of moderately to severely active UC; age >=6; prescribed by or in consultation with a gastroenterologist

Response assessment

Improvement measures: Improvement in at least one: stool frequency, rectal bleeding, urgency of defecation, CRP, fecal calprotectin, mucosal appearance on endoscopy/CTE/MRE/intestinal ultrasound, improvement on disease activity scoring tool (e.g., UCEIS, Mayo)
Question 206

Rheumatoid arthritis - Continuation of therapy

Baseline requirements: Diagnosis of moderately to severely active RA; adult; prescribed by or in consultation with a rheumatologist
Questions 300-302
Continuation specifics: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response? Has patient experienced >=20% improvement in tender/swollen joint count, pain, or disability?
Questions 303-306

Ankylosing spondylitis / nr-axSpA - Continuation of therapy

Baseline requirements: Patient adult; prescribed by or in consultation with a rheumatologist
Questions 400-401
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response? Improvement in functional status, total spinal pain, morning stiffness, swollen/tender joints, CRP
Questions 402-405

Psoriatic arthritis - Continuation of therapy

Baseline requirements: Patient adult; prescribed by or in consultation with rheumatologist or dermatologist
Questions 500-501
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response? Improvement in swollen/tender joint counts, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, CRP
Questions 502-505

Plaque psoriasis - Continuation of therapy

Baseline requirements: Diagnosis of moderate to severe plaque psoriasis; adult; prescribed by or in consultation with a dermatologist
Questions 600-602
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response? Reduction in BSA affected from baseline; improvement in signs/symptoms (itching, redness, flaking, scaling, burning, cracking, pain)
Questions 603-607

Behcet's disease - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with a rheumatologist
Question 750
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response?
Questions 751-753

Hidradenitis suppurativa - Continuation of therapy

Baseline requirements: Diagnosis of severe, refractory HS; prescribed by or in consultation with a rheumatologist or dermatologist
Questions 800-801
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Improvement in reduction in abscess/inflammatory nodule count, reduced new sinus tracts/scarring, decreased lesion frequency, pain reduction, reduced suppuration, improved relapse frequency, QoL, or disease severity tool
Questions 802-805

Pyoderma gangrenosum - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with a dermatologist
Question 825
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response?
Questions 826-828

Sarcoidosis - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with dermatologist, pulmonologist, rheumatologist, cardiologist, neurologist, or ophthalmologist
Question 850
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response?
Questions 851-853

Takayasu's arteritis - Continuation of therapy

Baseline requirements: Diagnosis of refractory Takayasu's arteritis; prescribed by or in consultation with a rheumatologist
Questions 870,875-877
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response?
Questions 876-878

Uveitis - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with an ophthalmologist or rheumatologist
Question 900
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Improvement: reduced frequency of recurrence, zero or reduced anterior chamber inflammation, decreased reliance on topical corticosteroids
Questions 901-904

Reactive arthritis - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with a rheumatologist
Question 925
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Improvement in tender joint count, swollen joint count, or pain
Questions 926-928

Immune checkpoint inhibitor-related inflammatory arthritis - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with oncologist, hematologist, or rheumatologist
Questions 960-962
Response assessment: Is request for continuation? Is patient receiving via samples/assistance? Has patient achieved or maintained positive clinical response? Does patient have moderate or severe immunotherapy-related inflammatory arthritis? Has patient had inadequate response to corticosteroids and/or to a conventional synthetic drug, or intolerance/contraindication?
Questions 963-968

Immune checkpoint inhibitor-related toxicity - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with appropriate specialist (oncologist, gastroenterologist, hematologist)
Question 950
Response assessment: Has patient experienced inadequate response to systemic corticosteroids OR intolerance/contraindication to corticosteroids? (Yes -> No further questions/pathway)
Questions 951-953

Acute graft versus host disease - Continuation of therapy

Baseline requirements: Prescribed by or in consultation with an oncologist or hematologist
Question 975
Response assessment: Has patient experienced inadequate response to systemic corticosteroids OR intolerance/contraindication?
Questions 976-978

Result options: Positive for TB; Negative for TB; Unknown

Selections route accordingly

If TB positive - latent vs active and treatment status: If TB positive, indicate: latent TB treatment initiated; latent TB treatment completed; latent TB treatment not initiated; active TB

Question 5; All continue to #9

Indication selection branching

Indication selection: Select single diagnosis to follow corresponding numbered questions

Question 9; each selection continues to its numbered section (e.g., Crohn's -> #100, UC -> #200, RA -> #300, AS/nr-axSpA -> #400, PsA -> #500, PsA with plaque psoriasis -> #10, Plaque psoriasis -> #600, Behcet's -> #750, HS -> #800, Pyoderma gangrenosum -> #825, Sarcoidosis -> #850, Takayasu's -> #870, Uveitis -> #900, Reactive arthritis -> #925, ICI-related toxicity -> #950, ICI-related inflammatory arthritis -> #960, Acute GVHD -> #975; Other -> No Further Questions)

Clinical screening questions (flow logic) capturing 963-993 and dosing branching

Question 963: Has the patient achieved or maintained a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms since starting treatment with the requested drug?

Yes -> Continue to #990; No -> Continue to #990

Question 964: Does the patient have moderate or severe immunotherapy-related inflammatory arthritis?

Yes -> Continue to #965; No -> Continue to #965

Question 965: Has the patient had an inadequate response to corticosteroids?

Yes -> Continue to #990; No -> Continue to #966

Question 966: Has the patient had an inadequate response to a conventional synthetic drug (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine)?

Yes -> Continue to #990; No -> Continue to #967

Sarcoidosis section (967-968)

Question 967: Does the patient have an intolerance or contraindication to corticosteroids?
Continue to #968
Question 968: Does the patient have an intolerance or contraindication to a conventional synthetic drug (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine)?
Yes -> Continue to #990; No -> Continue to #990

Acute graft versus host disease section (975-978)

975: Is requested drug prescribed by or in consultation with an oncologist or hematologist?
Yes -> Continue to #976; No -> Continue to #976
976: Has the patient experienced an inadequate response to systemic corticosteroids?
Yes -> Continue to #990; No -> Continue to #977
977: Does the patient have an intolerance to corticosteroids?
Yes -> Continue to #990; No -> Continue to #978
978: Does the patient have a contraindication to corticosteroids?
Yes -> Continue to #990; No -> Continue to #990

Dosing/product branching (990-993)

Question 990: Which diagnosis for dosing? (list of diagnoses routes to 991 or 993 per form)
See Question 990
Question 991: What is the prescribed product? Avsola, Inflectra, infliximab, Remicade, or Renflexis -> No Further Questions; Zymfentra -> Continue to #992
Question 991
Question 992: What is the patient's age? Less than 18 years old -> No Further Questions; 18 years or older -> No Further Questions
Question 992 (used if Zymfentra selected)
Question 993: What is the prescribed product? Avsola, Inflectra, infliximab, Remicade, or Renflexis -> No Further Questions; Zymfentra -> No Further Questions
Alternate product branching per form

Was a TB test (TST or IGRA) done within 12 months of initiating therapy?
Record TB test result: Positive, Negative, or Unknown
If positive, indicate latent vs active TB and whether treatment was initiated, completed, or not initiated

Documentation Required

Document prior therapy and intolerance/contraindications

Document prior use of biologic or targeted synthetic therapies and prior trials of conventional therapies as applicable to the indication. For initial therapy branches, indicate prior biologic/targeted synthetic use (or absence) and, when required, document trials and outcomes of conventional agents (e.g., methotrexate, leflunomide, NSAIDs, phototherapy, systemic agents, oral antibiotics) and any intolerance or contraindication that precludes their use.

Indicate prior biologic or targeted synthetic drugs received (or current use) relevant to the indication
Document trials of conventional therapies (e.g., methotrexate, leflunomide, NSAIDs, phototherapy, antibiotics) and duration/outcome
If conventional therapy not used, document clinical reason (intolerance, contraindication, drug interaction, pregnancy, comorbidity, hypersensitivity, history of adverse event, or other)

Documentation Required

Specialist involvement requirement

For many indications the requested drug must be prescribed by or in consultation with a relevant specialist. Indicate the specialist involved (e.g., gastroenterologist, rheumatologist, dermatologist, ophthalmologist, oncologist, hematologist, pulmonologist, cardiologist, neurologist) and include the specialist name and NPI on the form.

Confirm prescription is by or in consultation with the required specialist for the indication
Enter specialist name and NPI on the form

Documentation Required

Send completed form to CVS Caremark Specialty Programs

Send the fully completed form to CVS Caremark Specialty Programs via fax at 1-866-237-5512. By signing the form, prescribers attest that documentation supporting the responses is available for review if requested by CVS Caremark or the benefit plan sponsor.

Fax completed form to CVS Caremark Specialty Programs: 1-866-237-5512
Attest that supporting documentation is available for review if requested

Documentation Required

Prescriber attestation and signature

The prescriber or an authorized representative must sign and date the form to attest that the information provided is accurate and that supporting documentation is available for review if requested.

Prescriber or authorized signature is required
Date (mm/dd/yy) is required