CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSACOM Prior Authorization Request (CVS Caremark specialty drug PA form)

A prior authorization form and questionnaire used by CVS Caremark to collect information required for coverage decisions for specialty medications under the HMSA prescription benefit; it applies to prescribers requesting PA for specialty drugs for HMSA members.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSACOM Prior Authorization Request (CVS Caremark specialty drug PA form)

Policy CodePolicy N/A

Change TypeAdministrative — form/questionnaire content only

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed CVS Caremark Specialty Programs prior authorization form to 1-866-237-5512 with required chart notes and proposed treatment plan when requested.

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POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Fax: 1-866-237-5512primary submission channel

Phone: 1-808-254-4414CVS Caremark contact

CaremarkConnect: 1-800-237-2767specialty customer care

Questions 101-114decision questionnaire length

Coverage Criteria and Decision Flow

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSACOM Prior Authorization Request (CVS Caremark specialty drug PA form)

Policy CodePolicy N/A

Change TypeAdministrative — form/questionnaire content only

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed CVS Caremark Specialty Programs prior authorization form to 1-866-237-5512 with required chart notes and proposed treatment plan when requested.

SourceLink

On This Page

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PA questionnaire decision tree

Authorization follows a branching questionnaire; coverage determinations depend on answers to the numbered questions below.

Primary flow: If member type and diagnosis answers follow branching (questions 101-114) and required documentation is provided, proceed to authorization review.

This node represents the overall flow of the form; specific branches below capture condition checks.

Diagnosis branching for alopecia: If the requested drug is prescribed for alopecia (A51.3, L63, L64) follow the alopecia branch (questions 102/103/104).

Follow the routing indicated by questions 102 and 103 based on Federal member status.

QUEST/Federal member checks: Question 101 determines Federal member status and routes between question 102 or 103; question 104 determines QUEST member status and routes to infertility screening (question 105).

Responses guide subsequent required information and routing to infertility or generic/OTC checks.

Infertility/enhanced fertilization check: Question 105 asks whether the request is for infertility or to enhance fertilization; affirmative responses proceed to the generic/OTC check (question 106).

This branch may affect coverage determinations and required documentation.

Generic/OTC equivalent check: Question 106 asks whether an FDA-approved A-rated generic equivalent or an OTC with a generic equivalent exists; presence of such alternatives is recorded and routing continues to the FDA indication check (question 107).

May influence step-therapy or coverage decisions.

FDA-approved indication check: Question 107 asks if the prescribed drug is for an FDA-approved indication; a 'No' response continues the form but may require additional justification or lead to denial if documentation is not provided.

If not for an FDA-approved indication, supporting documentation should be attached (see question 112).

New start vs continuation branching: Question 108 distinguishes new starts versus continuation of therapy; new starts proceed to initial therapy flow (question 112 onward) while continuations proceed to verification of prior authorization (question 109).

Continuation requests require prior authorization history and evidence of response where applicable (question 111).

Prior authorization verification for continuations: If continuation of therapy, question 109 asks whether this was previously authorized by CVS/HMSA for this member; a 'Yes' routes to drug-specific checks (question 110) and a 'No' routes to the new start flow.

Evidence of response to treatment (question 111) should be attached when applicable.

Drug-specific checks (Tepezza, Vyvgart): Question 110 asks whether the requested drug is Tepezza; question 113 asks whether the drug is Vyvgart and, if Vyvgart, question 114 confirms a diagnosis of generalized myasthenia gravis.

Vyvgart requires affirmative diagnosis of generalized myasthenia gravis (question 114) to continue.

Submission, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization must be requested by completing and faxing the CVS Caremark Specialty Programs prior authorization form to CVS Caremark at 1-866-237-5512. For prior authorization questions, contact CVS Caremark at 1-808-254-4414. For Specialty Customer Care Team inquiries (eligibility, copay, medication delivery), contact CaremarkConnect at 1-800-237-2767 or CaremarkConnect@cvscaremark.com. Approvals may be subject to dosing limits per FDA labeling, accepted compendia, and evidence-based guidelines.

Send completed form to: CVS Caremark Specialty Programs Fax: 1-866-237-5512
Phone: 1-808-254-4414 for prior authorization questions
Specialty Customer Care Team: CaremarkConnect 1-800-237-2767 or CaremarkConnect@cvscaremark.com

Denial Risk

Generic / OTC Check

The prior authorization form asks whether an FDA‑approved A‑rated generic equivalent or an over‑the‑counter (OTC) product with a generic equivalent exists (question 106). If a therapeutically equivalent generic or OTC alternative is available, this may affect coverage or authorization decisions.

Question 106: Is there an FDA‑approved A‑rated generic equivalent or an OTC with a generic equivalent for the requested drug? (Yes/No)

Documentation Required

Required Documentation

Chart notes or other clinical information supporting the diagnosis and the proposed treatment plan must be submitted by the prescriber when requested. The form specifically asks that current clinical documentation (office visit notes and applicable studies) supporting response to prior treatment be attached when applicable (question 111). Requests may be denied if required documentation is not provided.

Question 112: The following documentation is required for authorization: (1) chart notes or clinical information supporting the diagnosis, and (2) proposed treatment plan — will these be submitted by the prescriber? (Yes/No)
Question 111: Attach evidence to support response to treatment (e.g., office visit notes, studies) when applicable
Requests may be denied if chart notes, proposed treatment plan, or other requested documentation are missing

Denial Risk

Denial Triggers

Requests may be denied if the requested drug is not being prescribed for an FDA‑approved indication or if required documentation is missing. Ensure the diagnosis corresponds to an FDA‑approved indication and that all requested supporting documentation is supplied.

Question 107: Is the prescribed drug for an FDA‑approved indication? (Yes/No)
Denial triggers: non‑FDA indication, missing chart notes, missing proposed treatment plan, or failure to provide requested clinical documentation

Criteria for Continuation (Renewal) Authorization

Continuation requirements

Continuation requests require prior authorization history and evidence of response where applicable.

Continuation verification: If continuation of therapy (question 108), verify prior authorization for this member (question 109).

If previously authorized by CVS/HMSA, proceed with drug-specific checks; if not, treat as a new start and follow initial therapy routing.

Evidence of response: Attach evidence to support response to prior treatment when requested (question 111) such as current clinical documentation, office visit notes, and applicable studies.

Submission of chart notes and the proposed treatment plan is required for authorization per question 112.

Step	Question (form #)	Implication for coverage
1	Is there an FDA‑approved A‑rated generic equivalent or an over‑the‑counter (OTC) product with a generic equivalent for the requested drug? (Question 106)	If yes, the form continues to subsequent questions (Question 107) and the presence of an A‑rated generic/OTC equivalent may influence step therapy requirements or coverage review; if no, the form also continues to Question 107 — responses guide whether additional justification is needed.

Key Definitions

New start vs Continuation (Question 108)

Question number108

PurposeDistinguishes whether the request is a new start or a continuation of therapy to determine the appropriate authorization pathway (new start proceeds to #112; continuation proceeds to #109).

New start pathwayIf 'New Start', the form directs the user to question 112 to collect required documentation and authorization information.

Continuation pathwayIf 'Continuation of Therapy', the form directs the user to question 109 to verify whether the therapy was previously authorized for this member.

Required follow-up when continuation is answered 'Yes'If previously authorized by CVS/HMSA (question 109 = Yes), the form proceeds to question 110 for drug-specific checks.

Required follow-up when continuation is answered 'No'If previously not authorized (question 109 = No), the form returns to the new-start documentation flow (proceeds to #112).

Background and Scope

This document is an administrative prior authorization form used to collect the clinical and administrative details needed for specialty drug review. The form is structured as a branching questionnaire (questions 101–114) that captures member type, diagnosis (including example ICD‑10s for alopecia), site of care, whether a product has an FDA‑approved generic or OTC equivalent, indication status, and whether the request is a new start or continuation. The completed form and any required supporting documentation must be submitted to CVS Caremark Specialty Programs via fax to 1‑866‑237‑5512 for processing.

OpenPayer

HMSACOM Prior Authorization Request (CVS Caremark specialty drug PA form)

Coverage Criteria and Decision Flow

Example Diagnosis / Procedure Codes

Submission, Documentation, and Provider Requirements

Criteria for New Start (Initial) Authorization

Criteria for Continuation (Renewal) Authorization

Step Therapy / Alternative Options

Dispensing and Administration Site

Key Definitions

Background and Scope

A51.3	ICD-10 code listed as an example for alopecia
L63	ICD-10 code listed as an example for alopecia
L64	ICD-10 code listed as an example for alopecia