CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSA - Prior Authorization Request

A prior authorization request form administered by CVS Caremark on behalf of HMSA for medications requiring prior authorization, specifically including Signifor; collects clinical, dispensing/administration site, diagnosis, prior therapy, and laboratory response documentation to determine coverage.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSA - Prior Authorization Request

Policy CodePolicy N/A

Change TypeClarified (form date onlyno material change)

Effective Date

Next Review Date

Key ActionFax completed prior authorization form with required clinical documentation to CVS Caremark Specialty Programs at 1-866-237-5512 for review; contact CVS Caremark at 1-808-254-4414 with questions.

SourceLink

POLICY UPDATE CHANGES

Form header/footer indicates 'Signifor HMSA - 10/2023'.

1Primary drug referenced

1Primary indication listed (Cushing's syndrome/disease)

4Acceptable cortisol tests

Coverage Summary

Scope: A prior authorization request form administered by CVS Caremark on behalf of HMSA for medications requiring prior authorization, specifically including Signifor; collects clinical, dispensing/administration site, diagnosis, prior therapy, and laboratory response documentation to determine coverage.

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Authorization / Clinical Criteria

Authorization Criteria for Signifor

Covered when ALL of the following are met:

Diagnosis / ICD-10: Drug prescribed for diagnosis of Cushing's syndrome/disease or other provided diagnosis
Provider must indicate diagnosis and ICD-10 code on form
Endocrinologist involvement: Signifor is prescribed by or in consultation with an endocrinologist
Question on form asks Yes/No
Documentation of cortisol testing (either pre-treatment or on-treatment) required
- On-therapy cortisol documentation: On-therapy reduction in cortisol level documented by one of: Urinary free cortisol (UFC), Late-night salivary cortisol, 1 mg overnight dexamethasone suppression test (DST), or low-dose DST (2 mg/day for 48 hours)Measured by UFC, late-night salivary cortisol, 1 mg overnight DST, or low-dose DST (2 mg/day for 48 hours)
  If yes, attach documentation of current cortisol level; if yes and patient already on therapy, no further questions
- Pretreatment cortisol documentation: Pretreatment cortisol level documented by one of: Urinary free cortisol (UFC), Late-night salivary cortisol, 1 mg overnight dexamethasone suppression test (DST), or low-dose DST (2 mg/day for 48 hours)Measured by UFC, late-night salivary cortisol, 1 mg overnight DST, or low-dose DST (2 mg/day for 48 hours)
  If yes, attach documentation of pretreatment cortisol level
Prior therapy / surgical status branch
- Currently receiving Signifor: Patient currently receiving Signifor therapy
  If Yes, question asks whether therapy was previously authorized by HMSA/CVS; if previously authorized, attach documentation of response (see cortisol reduction/improvement questions)
- Non-curative surgery: Patient had surgery that was not curative
  If Yes, attach documentation of pretreatment urinary free cortisol level; if Yes, no further questions
- Not candidate for surgery: Patient is not a candidate for surgery
  If No to candidacy, attach documentation of pretreatment urinary free cortisol level
Prescriber attestation signature confirming accuracy and availability of supporting documentation
Form requires prescriber signature and date

Operational / Administrative Questions

Information required to process the PA request (must be provided):

Dispensing site indicated (office, outpatient hospital, ambulatory surgical, inpatient hospital, pharmacy, other)
Provider must state where drug is dispensed (multiple selectable options on form).
Administration site indicated (ambulatory surgical, home, inpatient hospital, office, outpatient hospital, pharmacy)
Patient demographics: name, ID, date of birth, phone, weight, height
Physician details: name, specialty, NPI, office phone, office fax
Attach lab documentation when indicated as stated elsewhere on form
If pretreatment or on-therapy cortisol levels exist or patient had non-curative surgery, attach documentation of urinary free cortisol, late-night salivary cortisol, or DST results as specified on the form.

Provider Actions & Submission Instructions

Prior Authorization

Submit prior authorization form to CVS Caremark

Fax the completed prior authorization form along with required clinical documentation to CVS Caremark Specialty Programs for review. Fax to 1-866-237-5512. For questions regarding the prior authorization, contact CVS Caremark at 1-808-254-4414.

Documentation Required

Attach cortisol lab documentation when indicated

If pretreatment or on-therapy cortisol levels are available or the patient had non-curative surgery, attach the relevant laboratory or postsurgical documentation. Acceptable cortisol tests include urinary free cortisol (UFC), late-night salivary cortisol, 1 mg overnight dexamethasone suppression test (DST), or a low-dose DST (2 mg/day for 48 hours).

Documentation Required

Indicate prescriber specialty and consultation

Indicate the prescriber's specialty on the form and answer whether Signifor is prescribed by or in consultation with an endocrinologist. Include documentation of endocrinologist involvement when applicable.

Documentation Required

Prescriber attestation and signature required

The prescriber or authorized signer must sign and date the form, attesting that the information is accurate and that supporting documentation is available for review if requested by CVS Caremark or the plan sponsor.

Billing Rule

Dispensing/administration site must be indicated

State where the drug will be dispensed and where it will be administered by selecting the appropriate options on the form (examples: office, outpatient hospital, ambulatory surgical, inpatient hospital, pharmacy, home, etc.).

Background

This is a prior authorization form used by CVS Caremark on behalf of HMSA to collect necessary clinical and administrative information to determine coverage for Signifor.

The form collects: diagnosis (including a selectable option for Cushing's syndrome/disease and a field for the ICD-10 code), prescriber specialty and NPI (including whether Signifor is prescribed by or in consultation with an endocrinologist), prior authorization/history of Signifor therapy, surgical candidacy or history of non-curative surgery, and documentation of cortisol testing (pretreatment or on-therapy) using urinary free cortisol (UFC), late-night salivary cortisol, 1 mg overnight DST, or low-dose DST (2 mg/day for 48 hours).

The form also requires prescriber attestation and signature and asks for dispensing and administration site information and patient demographics.

Definitions

UFCUrinary free cortisol

DSTDexamethasone suppression test

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSA - Prior Authorization Request

Policy CodePolicy N/A

Change TypeClarified (form date onlyno material change)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

HMSA - Prior Authorization Request

Coverage Summary

Authorization / Clinical Criteria

Operational / Administrative Questions

Provider Actions & Submission Instructions

Coding

Background

Revision History