CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSAMCD - Prior Authorization Request

A prior authorization request form and checklist administered by CVS Caremark for HMSA members to request coverage for RSV prophylaxis (e.g., Synagis) including demographic, clinical criteria questions, administration/dispensing site, dosing history, seasonality, and attestations required to make a coverage determination.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSAMCD - Prior Authorization Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed prior authorization request form to CVS Caremark toll-free at 1-866-237-5512 for determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

1Form pages / primary document

MultipleClinical branches

Aug 1-Feb 29Seasonality constraint

Policy overview and intent

This is a CVS Caremark‑administered prior authorization request form for HMSA members to request coverage for RSV prophylaxis (e.g., Synagis/palivizumab). The form captures patient demographics, prescriber information, dispensing and administration site, ICD‑10 diagnosis code entry, sequential clinical questions for medical necessity, dosing history (number of doses received this RSV season), seasonality (HMSA RSV season: August 1 to February 29), and prescriber attestation/signature.

Approvals may be subject to dosing limits, seasonality, and supporting documentation: the form notes approvals may be subject to dosing limits in accordance with FDA‑approved labeling, accepted compendia, and/or evidence‑based practice guidelines, and explicitly requests that birth records or other documentation (e.g., oxygen requirement, transplant status) may be provided for verification upon request.

Key thresholds and metadata

HMSA RSV season datesAugust 1 to February 29

RSV activity threshold (NREVSS)> 10% for the requested region

Dosing maximum indicatorForm captures doses received this season with branches for >6 doses, 5 doses, and <5 doses

Oxygen requirement for CLD>21% oxygen for at least the first 28 days after birth

Gestational age thresholds<31 weeks, 6 days; >32 weeks, 0 days; <28 weeks, 6 days; >29 weeks, 0 days

Age thresholds<12 months; 12 to <24 months; <24 months; ≥24 months; >24 months

Scope summaryA prior authorization request form and checklist administered by CVS Caremark for HMSA members to request coverage for RSV prophylaxis (e.g., Synagis), including demographics, clinical criteria, dosing history, seasonality, and attestations

Payer nameHMSA (CVS Caremark administers prior authorization)

Document type & statusadministrative prior authorization form; CURRENT

Medical necessity decision flow for Synagis (palivizumab)

General Authorization Decision Flow

Complete sequential questions to determine medical necessity for Synagis (palivizumab) during the RSV season or off-season; follow branching instructions listed with each question.

General information: Provide patient demographics and prescriber information (name, DOB, ID, NPI, contact info, weight, height, dispensing and administration site, ICD-10 code).

Demographics and site of dispensing/administration captured on the form.

Initial screening (Questions 1-2)

Q1 responses: Yes (Continue to #2)
Q1 responses: No (Continue to #2)

Screening (Question 2)

Q2 responses: Yes (Continue to #3)
Q2 responses: No (Continue to #3)

Diagnosis selection (Question 3)

Chronic lung disease of prematurity (Continue to #4)
CHD / persistent pulmonary hypertension: Congenital heart disease (CHD) and/or persistent pulmonary hypertension (Continue to #9)
Congenital airway: Congenital abnormality of the airway (Continue to #12)
Neuromuscular condition (Continue to #12)
Prematurity (Continue to #13)
Immunocompromised patients (Continue to #15)

Chronic lung disease of prematurity branch (Questions 4-8)

Question 4
- Q4 responses: <31 weeks, 6 days (Continue to #5)
- Q4 responses: >32 weeks, 0 days (Continue to #5)
Question 5
- Q5 responses: Yes (Continue to #6)
- Q5 responses: No (Continue to #6)
Question 6

CHD / persistent pulmonary hypertension branch (Questions 9-11)

Question 9
- Q9 responses: Yes (Continue to #10)
- Q9 responses: No (Continue to #10)
Question 10
- Q10 responses: <12 months (Continue to #17)
- Q10 responses: 12 to <24 months (Continue to #11)

Congenital airway / Neuromuscular branch (Questions 12-14)

Question 12
- Q12 responses: Yes (Continue to #14)
- Q12 responses: No (Continue to #14)
Question 13
- Q13 responses: <28 weeks, 6 days (Continue to #14)
- Q13 responses: >29 weeks, 0 days (Continue to #14)
Question 14

Immunocompromised branch (Questions 15-16)

Question 15
- Q15 responses: Yes (Continue to #16)
- Q15 responses: No (Continue to #16)
Question 16
- Q16 responses: <24 months (Continue to #17)
- Q16 responses: ≥24 months (Continue to #17)

Seasonality and dosing limits (Questions 17-22)

Question 17
- Q17 responses: Yes (Continue to #21)
- Q17 responses: No (Continue to #18)
Question 18
- Q18 responses: >6 doses (Continue to #19)
- Q18 responses: 5 doses (Continue to #19)

Attestation: Prescriber signature and date attesting information is accurate and supporting documentation is available for review.

Prescriber or authorized signature and date required.

Requested diagnosis and code entry

Requested diagnosis code entryICD-10

Form field: 'What is the ICD-10 code?' (provider to supply applicable ICD-10 code for indication)

What providers must do

Prior Authorization

Submit prior authorization form to CVS Caremark

Fax the completed prior authorization request form to CVS Caremark for determination. Fax: 1-866-237-5512. For questions, contact CVS Caremark at 1-808-254-4414.

Documentation Required

Provide supporting clinical documentation

Be prepared to provide birth records to verify gestational age and other supporting clinical documentation upon request to verify criteria such as oxygen requirement or transplant status.

Birth records to verify gestational age
Documentation of oxygen requirement (>21% for first 28 days) or ongoing respiratory support
Transplant or chemotherapy records to document immunocompromised status

Billing Rule

Indicate dispensing and administration site

Specify where the drug will be dispensed and where it will be administered on the form (office, outpatient hospital, pharmacy, home, etc.) to support coverage and proper claims processing.

Denial Risk

Seasonal and dosing limitations may affect approval

Requests outside HMSA RSV season or requests that exceed dosing expectations may affect approval. The form captures doses received this season and asks whether regional RSV activity (NREVSS) is > 10%; off-season requests and dosing >5 or >6 doses trigger additional review per the branching logic.

HMSA RSV season dates: August 1 to February 29 (off-season flag)
NREVSS RSV activity threshold: > 10% for the requested region
Dosing branches include >6 doses, 5 doses, and <5 doses

Documentation Required

Attestation and signature required

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

Background and defined terms

CVS Caremark administers the prescription benefit plan for HMSA members and requires prior authorization for certain medications (for example, Synagis).

The form states that approvals may be subject to dosing limits consistent with FDA‑approved labeling, accepted compendia, and/or evidence‑based practice guidelines.

Definitions

HMSA RSV season (definition)August 1 to February 29 as specified on the form

NREVSS (definition)CDC National Respiratory and Enteric Virus Surveillance System; used to determine regional RSV activity (>10% threshold on form)

Document revisions

CURRENTLatest

Document status: CURRENT. No material changes recorded; no dated revision entries were provided. This prior authorization form administered by CVS Caremark for HMSA members captures demographics, clinical criteria for Synagis (palivizumab) including gestational age, oxygen requirement (>21% for first 28 days), age thresholds, seasonality (HMSA RSV season Aug 1–Feb 29), dosing limits (>6, 5, <5 doses branches), and RSV activity threshold (NREVSS >10%). Providers must fax the completed form to CVS Caremark (toll-free 1-866-237-5512) and may be asked to provide supporting documentation (e.g., birth records). Approvals may be subject to dosing limits per FDA labeling, compendia, or evidence-based practice guidelines.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSAMCD - Prior Authorization Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed prior authorization request form to CVS Caremark toll-free at 1-866-237-5512 for determination.

SourceLink

On This Page

Other (No Further Questions)

Q6 responses: <12 months (Continue to #17)
Q6 responses: 12 to <24 months (Continue to #7)
Q6 responses: >24 months (No Further Questions)

Question 7

Q7 responses: Yes (Continue to #8)
Q7 responses: No (Continue to #8)

Question 8

Q8 responses: Oxygen (Continue to #17)
Q8 responses: Diuretic (Continue to #17)
Q8 responses: Chronic corticosteroid (Continue to #17)
Q8 responses: Other - specify (Continue to #17)

Q10 responses: >24 months (No Further Questions)

Question 11

Q11 responses: Yes (Continue to #17)
Q11 responses: No (Continue to #17)

Q14 responses: <12 months (Continue to #17)
Q14 responses: ≥12 months (Continue to #17)

Q18 responses: <5 doses (No Further Questions)

Question 19

Q19 responses: Yes (Continue to #20)
Q19 responses: No (Continue to #20)

Question 20

Q20 responses: Yes (No Further Questions)
Q20 responses: No (No Further Questions)

Question 21

Q21 responses: Yes (Continue to #22)
Q21 responses: No (Continue to #22)

Question 22: How many doses of Synagis has the patient received this RSV season? (free text number of doses)

Free text number entry; followed by prescriber attestation