CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSA/CVS Caremark Prior Authorization Request Form for Specialty Medications

This prior authorization form (administered by CVS Caremark) collects patient and clinical information, routes conditional screening questions that determine authorization, and describes documentation requirements for specialty and other prescription drugs for HMSA members.

Policy Summary

PayerHMSA

PolicyPrior Authorization Request Form for Specialty Medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the CVS Caremark Prior Authorization form with required clinical documentation to 1-866-237-5512 to obtain coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number to submit requests

2phone numbers listed for inquiries

100+numbered criteria questions

1required documentation items

Coverage Criteria and Decision Logic

Form-driven authorization criteria

Authorization decision follows the form-driven criteria tree; examples below capture key branches.

Patient/member type checks

Fed branch: If 'Yes' to 101 (Fed member) then apply Fed routing and continue to question 103; evaluate diagnosis-specific screening (Questions 103, 107)
Questions 101,103
QUEST branch
- Infertility screening: If prescribed for infertility or to enhance fertilization -> continue to question 106 to assess whether an FDA-approved A-rated generic or OTC generic equivalent exists
  Question 105-106

Policy Summary

PayerHMSA

PolicyPrior Authorization Request Form for Specialty Medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the CVS Caremark Prior Authorization form with required clinical documentation to 1-866-237-5512 to obtain coverage.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

What Providers Must Do

Prior Authorization

Submit Completed CVS Caremark Prior Authorization Form

Providers must complete and fax the CVS Caremark Prior Authorization form to the Specialty Programs Fax at 1-866-237-5512 (toll-free). The form requests patient identifiers, drug name, prescriber information (including NPI), and clinical details needed to adjudicate coverage. For questions about the prior authorization process contact CVS Caremark at 1-808-254-4414; for Specialty Customer Care inquiries (eligibility, copay, medication delivery) contact CaremarkConnect at 1-800-237-2767 or CaremarkConnect@cvscaremark.com.

Fax completed CVS Caremark Prior Authorization form to: 1-866-237-5512
Include patient name, ID, DOB, phone number, drug name, physician name, specialty, NPI, office phone and fax
Approvals may be subject to dosing limits consistent with FDA labeling and evidence-based guidelines

Step Therapy

Form-driven Step Checks and Branching Questions

The form uses branching (step) questions that route the request based on member type, diagnosis, prior authorization history, and availability of FDA‑approved generics or OTC alternatives. Answer each question on the form fully so the request follows the correct path (examples below).

Question 101: Is this request a Federally funded (Fed) member? Routes to different question sets based on Yes/No.
Questions 102–107: Screen for specific diagnoses (e.g., alopecia codes) and whether the drug is for a QUEST member, infertility, or has an FDA‑approved generic/OTC alternative.
Question 108–113: Identify new start vs continuation, prior CVS/HMSA authorization, drug‑specific routing (e.g., Tepezza, Vyvgart), and whether required documentation will be submitted.

Documentation Required

Required Clinical Documentation

Current clinical documentation must be submitted to support the diagnosis and demonstrate medical necessity. Submit chart notes and any applicable studies that document the condition, baseline status, and the proposed treatment plan. If continuation of therapy is requested, include evidence of prior authorization and documentation of response to treatment when applicable.

Required documentation: 1) Chart notes or clinical information supporting the diagnosis; 2) Proposed treatment plan
If continuation: include prior CVS/HMSA authorization details and objective evidence of response (office visit notes, applicable studies)
Attach all supporting records when faxing the prior authorization form

Denial Risk

Denial Risk — Common Triggers

Failure to complete the form, answer branching questions accurately, or provide the required supporting documentation may result in denial of the prior authorization request.

Denial triggers include: missing or incomplete prior authorization form, absence of chart notes or proposed treatment plan, lack of evidence of response for continuation requests, or omission of required routing answers (member type, diagnosis, prior authorization history)
If an FDA‑approved A‑rated generic or OTC equivalent exists and is not addressed per form instructions, coverage may be affected

Form Scope and Collected Information

The form collects core patient and treatment details needed for authorization decisions: patient demographics and clinical identifiers, the site where the drug will be dispensed and administered, and the requested ICD‑10 diagnosis code (the form includes a field “What is the ICD‑10 code?”). It also captures medication‑specific screening questions (for example, named products such as Tepezza and Vyvgart are explicitly checked in the flow) and directed questions about member type (e.g., QUEST or Fed member) that affect which branches and documentation requirements apply.

Member Type Definitions

Fed member (compact definition/flag)

DefinitionFed member: member type identified by Question 101 on the form; selection routes the form to the Fed-specific branch of the criteria tree (continue to #103 if Yes).

Form logicIf 'Yes' to Question 101 (Fed member), the form directs to Question 103 to assess diagnosis-specific screening (e.g., alopecia).

Action for providersAnswering 'Yes' or 'No' to the Fed member question changes subsequent required questions and documentation pathways on the form.

QUEST member (compact definition/flag)

DefinitionQUEST member: member type identified by Question 104 on the form; selection routes the form to QUEST-specific screening questions (continue to #105 if Yes).

Form logicIf 'Yes' to Question 104 (QUEST member), the form proceeds to assess whether the drug is prescribed for infertility or to enhance fertilization (Question 105) and other QUEST-specific checks.

ImplicationBeing a QUEST member may trigger additional screening (e.g., infertility-related checks) that affect authorization requirements and required documentation.

Initial Therapy Requirements

Initial therapy requirements

New start requests are routed through initial therapy checks including FDA-approved indication and member-type based questions.

Initial therapy checks: For new starts, confirm the prescribed medication is for an FDA‑approved indication (Question 107) and complete required documentation (Question 112).

Questions 107,108,112

Member-type routing: Confirm member type: If Fed member (Question 101) follow Fed routing; if QUEST member (Question 104) evaluate infertility use and generic/OTC equivalents (Questions 105-106) which may affect authorization pathway.

Questions 101,104-106

Generic/OTC screening: If QUEST screening indicates infertility or related use, determine whether an FDA‑approved A‑rated generic or OTC with a generic equivalent exists; a 'Yes' directs to standard routing (Question 106).

Question 106

Site of care / dispensing info: Provider must indicate where the drug will be dispensed and administered on the form; this information is collected as part of the submission.

Form fields (site of care)

Continuation Therapy Requirements

Continuation therapy requirements

Continuation requests must document prior authorization history and evidence of response when requested.

Prior authorization history: Was this previously authorized by CVS/HMSA for this member? If 'Yes', provide prior authorization details and continue to evidence-of-response checks (Question 109).

Question 109

Evidence of response: If previously authorized, submit current clinical documentation demonstrating response to treatment (e.g., office visit notes, applicable studies). The form asks specifically whether there is evidence to support response to treatment (Question 111).

Question 111

If no prior authorization: If not previously authorized for this member, the request is routed to the new-start pathway requiring documentation per initial therapy checks (Questions 109 -> 112).

Questions 109-112

Required documentation for renewal: For continuation approvals, attach chart notes or clinical information supporting ongoing diagnosis and treatment plan; the prescriber must attest that documentation will be available or submit it with the form (Question 112).

Question 112

Step Therapy and Therapeutic Alternatives

Step	Question / screening item	Action on form
1	Is this request a Fed member? (Q101)	If Yes → Continue to #103; If No → Continue to #102
2	Is the requested drug being prescribed for Alopecia (A51.3, L63, L64)? (Q102 / Q103)	If Yes → Continue to #104 (or #107 per branch); If No → Continue to next indicated question
3	Is this request for a QUEST member? (Q104)	If Yes → Continue to #105; If No → Continue to #107
4	Is the drug prescribed for infertility or to enhance fertilization? (Q105)	If Yes or No → Continue to #106
5	Is there an FDA‑approved A‑rated generic equivalent or an over‑the‑counter (OTC) that has a generic equivalent for the requested drug? (Q106)	If Yes → Continue to #107; If No → Continue to #107 (form proceeds to FDA‑indication check)
6	Is the prescribed drug for an FDA‑approved indication? (Q107)	If Yes → Continue to #108; If No → Continue to #108 (routes to further assessment/possible denial)
7	Is this request a new start or continuation of therapy? (Q108)	New Start → Continue to #112; Continuation → Continue to #109
8	Was this previously authorized by CVS/HMSA for this member? (Q109)	If Yes → Continue to #110; If No → Continue to #112
9	Is the requested drug Tepezza? (Q110)	If Yes → Continue to #112; If No → Continue per form flow
10	Is there evidence to support response to treatment? (attach clinical documentation) (Q111)	If Yes → No further questions; If No → No further questions (documentation requirement noted)
11	Will required documentation (chart notes and proposed treatment plan) be submitted by prescriber? (Q112)	If Yes → Continue to #113; If No → Continue to #113 (form documents requirement for authorization)
12	Is the requested drug Vyvgart? (Q113)	If No → No further questions

OpenPayer