CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization form — biologic and targeted synthetic therapies for psoriasis, psoriatic arthritis, ankylosing spondylitis and non-radiographic axial spondyloarthritis

CVS Caremark‑administered prior authorization form used by HMSA to document clinical criteria and provider attestation for coverage decisions of biologic and targeted synthetic drugs for plaque psoriasis, psoriatic arthritis, ankylosing spondylitis and non-radiographic axial spondyloarthritis; affects prescribers and patients seeking coverage for these specialty medications.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization form — biologic and targeted synthetic therapies for psoriasis, psoriatic arthritis, ankylosing spondylitis and non-radiographic axial spondyloarthritis

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form to CVS Caremark at 1-866-237-5512 or contact 1-808-254-4414 for inquiries.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4primary indications

300+form fields (approx)

1-866-237-5512fax to submit

1-808-254-4414prior auth phone

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Coverage Criteria Overview

Indication-specific initial and continuation criteria

Coverage decisions are guided by indication-specific branching logic; the requested drug is covered when ALL criteria in the applicable indication pathway are met.

Indication selection: Patient has one of: plaque psoriasis; psoriatic arthritis (with or without co-existent plaque psoriasis); ankylosing spondylitis; non-radiographic axial spondyloarthritis

See the applicable indication pathway below

TB screening: Has tuberculosis screening (TST or IGRA) within the prior 12 months with documentation of result; if positive, documentation of latent TB treatment initiation/completion or active TB status

Questions capture TB testing and results

Moderate to severe plaque psoriasis pathway (initial and continuation): Initial: Diagnosis of moderate to severe plaque psoriasis; age ≥6 years; prior biologic/targeted synthetic use (excluding samples/PAP) disqualifies from initial-therapy pathway. If biologic-naive, one of the following is required: involvement of crucial body areas OR BSA ≥3% OR inadequate response/intolerance to phototherapy or systemic agents (methotrexate, cyclosporine, acitretin) OR clinical reason to avoid those agents. Continuation: patient demonstrates maintained or improved clinical response (low disease activity or improvement in signs/symptoms) and reduction in BSA or other documented benefit.BSA categories: <3%; ≥3% to <10%; ≥10%

See questions #100-#114 for initial criteria and #103-#107 for continuation

Psoriatic arthritis pathway (initial and continuation): Initial: Diagnosis of active psoriatic arthritis. Prior biologic/targeted synthetic use (excluding samples/PAP) disqualifies from the initial-therapy pathway. For biologic-naive patients, inadequate response or intolerance to conventional synthetic DMARDs (e.g., methotrexate, leflunomide, sulfasalazine) at adequate dose/duration is required unless a listed intolerance/contraindication or other exception applies. Continuation: patient demonstrates maintained or improved signs/symptoms or disease-specific measures (e.g., decreased tender/swollen joints, improved functional status, decreased CRP).

See questions #210-#218 and #202-#205 for continuation details

Ankylosing spondylitis / non-radiographic axial spondyloarthritis pathway (initial and continuation): Initial: Diagnosis of active AS or nr-axSpA in an adult. Prior biologic/targeted synthetic use (excluding samples/PAP) disqualifies from the initial-therapy pathway. Required prior therapy: inadequate response, intolerance, or contraindication to at least TWO NSAIDs. Continuation: patient demonstrates maintained or improved clinical response (e.g., reduced spinal pain, improved function, decreased inflammation or CRP).

See questions #300-#308 and #302-#305 for continuation details

Continuation across indications: Current users must show evidence of maintained clinical benefit demonstrated by disease-specific outcome measures (examples: BSA reduction, reduced number of tender or swollen joints, improvement in dactylitis/enthesitis/axial disease, improved functional status, decreased CRP). Requests where the patient receives the drug only via samples or manufacturer's patient assistance program are handled separately and do not count as prior biologic use for initial-therapy pathways.

See continuation sections for each indication (#103-#107, #202-#205, #302-#305) and exclusion handling for samples/PAPs

The form specifies that prior exposure to the requested biologic or targeted synthetic agent does not include receipt solely via drug samples or a manufacturer's patient assistance program. Receipt of the drug through samples or a manufacturer's patient assistance program will not be counted as prior biologic/targeted synthetic use for the purposes of initial-therapy pathways and may alter the coverage determination.

Providers should document any prior biologic/targeted synthetic use clearly on the form and not rely on sample or patient assistance program provision to satisfy prior-therapy questions.

Initial-therapy pathways require documented trials of indicated prior treatments unless a listed exception applies. For plaque psoriasis this includes evidence of involvement of crucial body areas, BSA ≥3%, or an inadequate response or intolerance to phototherapy or systemic agents (eg methotrexate, cyclosporine, acitretin), or a clinical reason to avoid those agents. For psoriatic arthritis, an inadequate response, intolerance, or contraindication to conventional synthetic DMARDs (eg methotrexate, leflunomide, sulfasalazine) is required unless an exception is documented. For ankylosing spondylitis and non-radiographic axial spondyloarthritis, failure or intolerance to at least two NSAIDs (or documented contraindication) is required prior to biologic/targeted therapy initiation.

When a required prior therapy has not been tried and no documented contraindication or intolerance exists, initiation of the requested biologic/targeted synthetic drug may be considered not medically necessary. Providers must use the form fields to indicate prior treatments, responses, intolerances, or contraindications to support exceptions.

Initial Therapy Requirements

Initial therapy criteria

Initial therapy is covered when ALL criteria in the indication-specific pathway below are satisfied.

Psoriasis initial: Diagnosis of moderate to severe plaque psoriasis; patient is ≥6 years of age; patient has not previously received a biologic or targeted synthetic therapy for psoriasis (excluding receipt via samples or manufacturer PAP) OR if prior biologic use is present, follow applicable prior-biologic rules. For biologic‑naive patients, at least one of the following is required: involvement of crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) OR BSA ≥3% OR inadequate response or intolerance to phototherapy (UVB, PUVA) or systemic pharmacologic therapy (methotrexate, cyclosporine, acitretin) OR documented clinical reason to avoid those systemic agents.BSA categories: <3%; ≥3% to <10%; ≥10%

See questions #100-#114

Psoriatic arthritis initial: Diagnosis of active psoriatic arthritis. Patient has not previously received a biologic or targeted synthetic therapy for PsA (excluding samples/PAP), or if biologic‑naive then meets severity/treatment failure requirements. Biologic‑naive patients must have had an inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD administered at adequate dose and duration, or have an intolerance or contraindication to these agents as documented (examples include pregnancy planning, liver disease, drug interaction, significant comorbidity, hypersensitivity). Presence of enthesitis or predominantly axial disease may alter pathway.

See questions #210-#218

AS / nr-axSpA initial: Diagnosis of active ankylosing spondylitis or active non‑radiographic axial spondyloarthritis in an adult. Patient has not previously received a biologic or targeted synthetic therapy for AS/nr‑axSpA (excluding samples/PAP). Required prior therapy: inadequate response to at least TWO NSAIDs, or intolerance/contraindication to at least two NSAIDs documented.

See questions #300-#308; trial of two NSAIDs required prior to biologic/targeted therapy initiation

Continuation Therapy Requirements

Continuation therapy

Continuation (renewal) coverage requires documentation that the patient has maintained or improved clinical benefit on the requested drug.

Continuation general: Request is for continuation of therapy and the patient is not receiving the requested drug solely via samples or a manufacturer's patient assistance program (such receipt is handled separately). The patient demonstrates maintained or improved signs and symptoms or disease‑specific measures since starting the requested drug (examples: reduction in BSA for psoriasis; decreased number of tender or swollen joints, improvement in dactylitis/enthesitis/axial disease, improved functional status, reduction in CRP).

Continuation questions: #103-#107 (psoriasis), #202-#205 (PsA), #302-#305 (AS/nr-axSpA)

Step Therapy and Trials

Step	Requirement	Evidence / Action
1	Failure, intolerance, or contraindication to at least two NSAIDs is required prior to initiating a biologic or targeted synthetic therapy for ankylosing spondylitis (AS) or non-radiographic axial spondyloarthritis (nr-axSpA).	Document inadequate response to ≥2 NSAIDs, or documented intolerance/contraindication to ≥2 NSAIDs; if met, continue with biologic/targeted therapy request. (See question #308 on the form.)

Key Clinical Coding & Severity Metrics

Body Surface Area (BSA) categories

BSA category< 3%

BSA category>= 3% to < 10%

BSA category>= 10%

Definitions and Clinical Measures

Crucial body areas (examples)

Examples of crucial body areasHands, feet, face, neck, scalp

Genital/groin involvementIncluded as a crucial body area that may influence treatment decisions

Intertriginous areasSkin fold regions (eg, intertriginous) considered crucial and may affect therapy choice

Tuberculosis (TB) testing

TB test types capturedTuberculosis skin test (TST) or interferon-release assay (IGRA)

Timing requirementTB test performed within 12 months of initiating therapy

Document resultsForm captures test result (positive, negative, unknown) and subsequent latent/active TB status or treatment initiation/completion

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Prior authorization through CVS Caremark is required for coverage. Fax the completed prior authorization form and supporting documentation to CVS Caremark Specialty Programs at 1-866-237-5512. For questions regarding prior authorization, contact CVS Caremark at 1-808-254-4414. For benefit/eligibility or copay questions, contact CaremarkConnect at 1-800-237-2767.

Fax: 1-866-237-5512
Phone (prior auth questions): 1-808-254-4414
CaremarkConnect (benefits/copay): 1-800-237-2767

Step Therapy

NSAID Trial Requirement

NSAID trial requirement for ankylosing spondylitis / nr-axSpA — For active ankylosing spondylitis or active non-radiographic axial spondyloarthritis, the patient must have had an inadequate response to, or intolerance/contraindication to, at least two NSAIDs prior to approval for a biologic or targeted synthetic therapy.

Applies to active AS and active nr-axSpA
Documentation of trial or intolerance/contraindication to ≥2 NSAIDs required

Documentation Required

Form Submission and Attestation

Form submission and prescriber attestation — Submit a completed prior authorization form with all requested clinical information. The prescriber or authorized signer must attest that the information is accurate and that supporting documentation is available for review upon request by CVS Caremark or the benefit plan sponsor.

Send completed form to CVS Caremark Specialty Programs
Fax: 1-866-237-5512
Include prescriber signature and date on the form

Denial Risk

Prior Therapy / Response May Trigger Denial

Prior therapy and current therapy considerations — Requests may be denied if required prior therapy trials are not documented or if the patient is currently receiving an indicated biologic/targeted synthetic (excluding samples or manufacturer patient assistance). Ensure documentation of prior medication trials, responses, intolerances, or contraindications is included to avoid denial.

Exclude sample or manufacturer patient assistance program receipt when documenting prior biologic/targeted synthetic use
Document inadequate response, intolerance, or contraindication to prior therapies as applicable
Lack of required prior trials or current use of an indicated biologic/targeted synthetic may result in denial

Site of Care Options

Note

Select site of care on the form

Indicate on the form the site where the drug will be dispensed and/or administered by selecting the appropriate setting (e.g., office, outpatient hospital, pharmacy, home, inpatient).

Dispense location options include Office, Outpatient Hospital, Pharmacy and others (see form checklist).
Administration location options include Home, Office, Outpatient Hospital, Pharmacy, Inpatient Hospital.

Policy Background

This prior-authorization form is designed to collect indication-specific clinical information needed to evaluate medical necessity for biologic and targeted synthetic drugs. It captures the diagnosis and disease activity/severity, prior treatments and responses (including prior biologic/targeted synthetic use excluding samples/PAPs), relevant disease measures (eg body surface area, involvement of crucial body areas, joint counts, pain/inflammation measures, CRP), and tuberculosis screening and results. Providers must complete the relevant sections to document severity, prior therapy trials, treatment response or intolerance, and TB testing to support initial or continuation coverage decisions.