CurrentHawaii Medical Service Association (HMSA)Policy N/A

Medicare Advantage Prior Authorization Fax Form (administered by CVS Caremark)

A prior authorization request form used by HMSA Medicare Advantage (administered by CVS Caremark) to collect patient, prescriber, and clinical information to determine coverage for certain prescription medications (example content specific to Simponi Aria). It defines required documentation, diagnosis selection, and clinical questions to support approval.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyMedicare Advantage Prior Authorization Fax Form (administered by CVS Caremark)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and fax the form to CVS Caremark at 1-866-237-5512 to request prior authorization and have supporting clinical documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes for this policy/form.

1Form Purpose (PA request)

Simponi AriaExample medication referenced

MultipleDiagnoses supported

Policy summary and purpose

This is an HMSA Medicare Advantage prior authorization fax form administered by CVS Caremark. It is used to collect necessary patient, prescriber, and clinical information to evaluate coverage and approvals for certain medications (example content specific to Simponi Aria). Providers are instructed to complete and fax the form to CVS Caremark at the toll-free number provided to request prior authorization.

CaremarkConnect is the Specialty Customer Care Team phone support line for inquiries related to eligibility, copay, or medication delivery: CaremarkConnect ® 1-800-237-2767.

Key metadata

PayerHawaii Medical Service Association (HMSA)

PolicyMedicare Advantage Prior Authorization Fax Form

SubjectMedicare Advantage Prior Authorization Fax Form for Medications (Simponi Aria example)

StatusCURRENT

Example medication referencedSimponi Aria

Scope summaryA prior authorization request form used by HMSA Medicare Advantage (administered by CVS Caremark) to collect patient, prescriber, and clinical information to determine coverage for certain prescription medications (example content specific to Simponi Aria). It defines required documentation, diagnosis selection, and clinical questions to support approval.

Prior authorization decision pathway

General Prior Authorization Decision Path

Complete the flow to support PA determination for Simponi Aria (and similar medications); route depends on current therapy and diagnosis.

General Prior Authorization Decision Path (root)

Demographics and dispensing/administration: Identify patient and prescriber demographics (name, ID, DOB, contact, NPI, specialty). Indicate where the drug will be dispensed and administered (multiple selectable options). Provide the ICD-10 diagnosis code for medication use.
Form requests these items for processing.
If patient currently receiving Simponi Aria
- Current therapy — select diagnosis: Select diagnosis: Rheumatoid arthritis; Psoriatic arthritis; Ankylosing spondylitis; Non-radiographic axial spondyloarthritis; Articular juvenile idiopathic arthritis; Immune checkpoint inhibitor-related inflammatory arthritis; Other.
  After selecting diagnosis, continue to the continuation/benefit question.
New-start diagnostic branch (when not currently receiving therapy)
- Diagnosis selection for new-start: Select diagnosis: Rheumatoid arthritis (continue to RA-specific questions); Active psoriatic arthritis; Active ankylosing spondylitis; Active non-radiographic axial spondyloarthritis; Active articular juvenile idiopathic arthritis; Immune checkpoint inhibitor-related inflammatory arthritis (continue to ICI branch); Other.
  Some diagnoses require further questions; others have no further questions.
- RA disease activity: If diagnosis is Rheumatoid arthritis, is the disease moderately to severely active?
  Answer Yes or No; continue to methotrexate question regardless.
- Methotrexate combination use: Will Simponi Aria be used in combination with methotrexate? If Yes, no further questions; if No, proceed to assess clinical reason to avoid methotrexate.
  If Yes, chart notes, medical record documentation, or claims history supporting previous medications tried and responses may be requested.
Continuation therapy assessment: For patients currently receiving Simponi Aria, ask if the patient is receiving benefit from therapy; chart notes or medical record documentation supporting benefit must be submitted upon request.
If Yes or No, no further questions; documentation should be available for review.

Attestation and signature: Provider attestation that information is accurate and documentation is available for review; prescriber or authorized signature and date required.

Signature attests documentation availability to support the PA request.

Diagnosis coding

ICD-10ICD-10

Form requests an ICD-10 code to be provided; specific codes not listed on form.

What providers must do

Prior Authorization

Submit completed PA fax form to CVS Caremark

Fax the completed prior authorization form to CVS Caremark at 1-866-237-5512. For questions about the PA, contact CVS Caremark at 1-808-254-4414.

Documentation Required

Maintain supporting clinical documentation

Keep chart notes and medical record documentation available upon request to support benefit from therapy, prior medication trials, clinical reasons to avoid methotrexate, intolerances or contraindications, and responses to prior therapies.

Billing Rule

Indicate dispensing and administration site

Indicate the dispensing site and the administration site selections on the form (multiple selectable options provided) to support PA processing.

Documentation Required

Provide ICD-10 diagnosis code

Provide the ICD-10 diagnosis code that corresponds to the indication for the requested medication on the form.

Denial Risk

Risk of denial if required documentation unavailable

Claims or prior authorizations may be denied or delayed if requested supporting documentation (for prior therapy failures, intolerances or contraindications, clinical reasons to avoid methotrexate, or documentation of benefit from ongoing therapy) is not available upon request.

Operational and logistics notes

Approvals may be subject to dosing limits consistent with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.

For questions regarding prior authorization processing, the form provides a CVS Caremark contact number and instructs providers to fax the completed form to CVS Caremark; the form also directs medication eligibility, copay, or delivery inquiries to the Specialty Customer Care Team at CaremarkConnect ® 1-800-237-2767.

Document changes

no_revision_history_provided

No revision history entries were provided for this document; has_material_change is false.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyMedicare Advantage Prior Authorization Fax Form (administered by CVS Caremark)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must complete and fax the form to CVS Caremark at 1-866-237-5512 to request prior authorization and have supporting clinical documentation available upon request.

SourceLink

On This Page

Reasons to avoid methotrexate: Does the patient have a clinical reason to avoid methotrexate (e.g., breastfeeding, pregnancy or planning pregnancy, renal or hepatic impairment, previous intolerance to methotrexate)?

If Yes, provide the clinical reason and supporting documentation upon request. If No, continue through additional assessment questions.

ICI-related inflammatory arthritis branch: For immune checkpoint inhibitor-related inflammatory arthritis, assess whether disease is moderate/severe and prior inadequate response to corticosteroids or conventional synthetic DMARDs; continue per guidance.

If continuing in this branch, supporting documentation for prior therapies and responses may be requested.

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

If Yes, submit chart notes/medical records or claims history upon request; if No, continue to intolerance/contraindication questions.

Intolerance/contraindication to corticosteroids: Does the patient have an intolerance or contraindication to corticosteroids?

If Yes, documentation may be requested and further questions follow.

Intolerance/contraindication to conventional synthetic DMARDs: Does the patient have an intolerance or contraindication to a conventional synthetic drug (e.g., methotrexate, sulfasalazine, leflunomide, hydroxychloroquine)?

If Yes, chart notes/medical records or claims history supporting previous medications tried and responses must be submitted upon request.