CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization form for medications to treat hereditary angioedema (HAE)

A CVS Caremark prior authorization request form used by HMSA Medicare Advantage to document diagnosis, laboratory/genetic confirmation, and continuation/initial therapy criteria for medications prescribed for hereditary angioedema (HAE). It defines required documentation and decision flow for approval.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization form for medications to treat hereditary angioedema (HAE)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax completed form to CVS Caremark toll-free at 1-866-237-5512 and provide required laboratory/genetic documentation or chart notes upon request.

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Primary diagnostic pathways (C1-INH deficient vs normal C1-INH)

1Required prior authorization contact (CVS Caremark fax)

1High-dose antihistamine trial requirement (when applicable)

Coverage Summary

This policy is covered with criteria. It uses a CVS Caremark prior authorization form for HMSA Medicare Advantage to evaluate medications prescribed for hereditary angioedema (HAE). Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines, and the form documents diagnosis, laboratory/genetic confirmation, and continuation/initial therapy criteria to guide coverage decisions.

Key thresholds and quick facts

Primary diagnostic pathways2 (C1‑INH deficiency/dysfunction vs normal C1‑INH)

Required prior authorization contactFax completed form to CVS Caremark at 1-866-237-5512

High‑dose antihistamine trial requirement (when applicable)Trial of high‑dose antihistamine (e.g., cetirizine 40 mg/day or equivalent) required and refractory to therapy

Threshold: cetirizine dosing and durationCetirizine 40 mg per day (or equivalent) for one month or longer

Initial Therapy Criteria

Initial therapy – C1-INH deficiency/dysfunction

For patients with HAE due to C1 inhibitor deficiency/dysfunction

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Initial therapy – C1-INH deficiency/dysfunction

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Initial therapy – C1-INH deficiency/dysfunction

Diagnosis Selection & Acute Indication

Diagnosis selection

Select the diagnosis that applies; directs subsequent questions

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Diagnosis selection

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Acute attack indication

Is the requested medication for treatment of acute HAE attacks?

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Acute attack indication

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Provider Actions & Documentation Requirements

Prior Authorization

Submit prior authorization request to CVS Caremark

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

Documentation Required

Provide laboratory and genetic documentation upon request

For HAE due to C1-INH deficiency or dysfunction, medical record documentation confirming C1-INH antigenic and functional protein levels must be available upon request. For HAE with normal C1-INH, provide genetic test results confirming F12, angiopoietin-1, plasminogen, KNG1, HS3ST6, or MYOF gene mutation, or chart notes documenting family history and that angioedema was refractory to a trial of high-dose antihistamine therapy.

Documentation Required

Continuation therapy documentation

For patients currently receiving the requested medication, chart notes demonstrating a reduction in severity and/or duration of acute attacks must be available upon request to support continuation of therapy.

Billing Rule

Specify dispensing and administration site

Indicate where the drug will be dispensed and where it will be administered (multiple checkbox options provided) to support appropriate benefit and claim routing.

Documentation Required

Attestation by prescriber

Prescriber or authorized signature and date are required, attesting that the information is accurate and that supporting documentation is available for review if requested.

Background

This prior authorization form is used to obtain coverage decisions for medications to treat hereditary angioedema (HAE) through CVS Caremark for HMSA Medicare Advantage. Approvals may be subject to dosing limits per FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines. The form collects patient and prescriber information, the dispensing and administration site, the ICD-10 diagnosis code, specific diagnosis selection (HAE with C1-INH deficiency/dysfunction or HAE with normal C1-INH), laboratory confirmation or genetic test results, documentation of refractory response to a high-dose antihistamine trial when applicable, and continuation benefit information including chart notes demonstrating reduction in attack severity/duration for ongoing therapy.

C1-INH: C1 inhibitor protein; antigenic and functional levels are used to confirm HAE due to C1-INH deficiency or dysfunction.

High-dose antihistamine trial: Example defined as cetirizine 40 mg per day or equivalent for one month or longer.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization form for medications to treat hereditary angioedema (HAE)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax completed form to CVS Caremark toll-free at 1-866-237-5512 and provide required laboratory/genetic documentation or chart notes upon request.

On This Page

OpenPayer

Prior authorization form for medications to treat hereditary angioedema (HAE)

Coverage Summary

Initial Therapy Criteria

Continuation Therapy Criteria

Diagnosis Selection & Acute Indication

Provider Actions & Documentation Requirements

Applicable Codes

Background

Clinical Evidence