CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization: CVS Caremark form for Entyvio (vedolizumab)

This document is a prior authorization request form administered by CVS Caremark for HMSA Medicare Advantage members; it governs requests for coverage of certain prescription drugs (notably Entyvio/vedolizumab) and applies to providers submitting authorization information for these medications.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization: CVS Caremark form for Entyvio (vedolizumab)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed CVS Caremark prior authorization form to 1-866-237-5512 and provide chart documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1primary medication

3diagnosis pathways

2prior therapy agents

1authorization fax

Coverage Determination Logic

Authorization decision logic

Coverage determination follows the form's question flow and depends on diagnosis, current Entyvio use, reported benefit from therapy, and prior therapy history or contraindications for checkpoint inhibitor–related toxicity.

Diagnosis selection

If UC or Crohn's: Continue to question 2 to establish current Entyvio use
If immune checkpoint inhibitor-related toxicity: Continue to question 10 to assess prior therapies or contraindications
If Other diagnosis: No further questions on this form
Form ends for other indications

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization: CVS Caremark form for Entyvio (vedolizumab)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed CVS Caremark prior authorization form to 1-866-237-5512 and provide chart documentation upon request.

SourceLink

On This Page

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Submission, Documentation, and Step-Therapy Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain medications administered under the patient's prescription benefit. Submit the completed prior authorization request and any supporting clinical documentation (chart notes, medical records, claims history) by fax to CVS Caremark toll-free at 1-866-237-5512. For questions regarding the prior authorization determination, contact CVS Caremark at 1-808-254-4414. For patient eligibility, copay, or medication delivery inquiries, contact CaremarkConnect® Specialty Customer Care at 1-800-237-2767.

Fax: 1-866-237-5512 (toll-free)
Prior authorization questions: 1-808-254-4414
Specialty Customer Care (CaremarkConnect): 1-800-237-2767

Step Therapy

Step Therapy / Prior Agent Verification

Step-therapy and prior-agent verification are required where indicated. If the clinical questions indicate the patient had an inadequate response or intolerance to systemic corticosteroids or infliximab, submit chart notes, medical record documentation, or claims history that shows prior medications tried and the response or intolerance. If the patient has a documented contraindication to systemic corticosteroids or infliximab, provide the clinical rationale in the submission; a clinician reviewer may assess the appropriateness of the rationale when making a determination.

Documented inadequate response or intolerance to systemic corticosteroids or infliximab — submit supporting chart notes/claims
If contraindication to corticosteroids or infliximab, provide clinical reason in submission for reviewer assessment

Documentation Required

Documentation Supporting Clinical Benefit and Prior Therapies

When requesting authorization for continued benefit from the requested medication, include chart notes or medical record documentation that supports clinical benefit. Examples include clinical assessments, objective measures of response, and treatment history. These records must be available upon request to facilitate timely review and approval.

If patient is currently receiving therapy and benefit is asserted, submit chart notes/medical records supporting benefit upon request
Include objective measures of response and treatment history when applicable

Denial Risk

Failure to Provide Accurate Diagnosis May Prevent Appropriate Determination

Providing the most accurate diagnosis for the prescribed medication is the provider's responsibility. Failure to provide an accurate or complete diagnosis and the supporting clinical information may prevent appropriate determination and can result in delay or denial of the prior authorization request.

Accurate diagnosis must be indicated on the prior authorization form
Incomplete or inaccurate diagnoses and missing documentation may result in denial or delayed determination

Initial Therapy Requirements

Initial therapy considerations — immune checkpoint inhibitor-related toxicity pathway and prior therapy requirements

For initial therapy requests in the setting of immune checkpoint inhibitor–related toxicity, the form requires verification of prior agent failure or intolerance before proceeding.

Prior agent failure or intolerance: Patient has had an inadequate response or intolerance to systemic corticosteroids or infliximab; chart notes, medical record documentation, or claims history supporting previous medications tried and response to therapy must be submitted upon request.

If answer is No, proceed to contraindication assessment (question 11)

If No prior failure/intolerance: Assess for contraindication to systemic corticosteroids or infliximab (provider must provide clinical reason). If contraindication present and documented, no further questions; clinician review may approve based on rationale.

Documentation of clinical reason must be submitted upon request

Continuation Therapy Requirements

Continuation therapy for Entyvio — documentation of clinical benefit required when requested

When the patient is currently receiving Entyvio, continuation of therapy is permitted when the member is deriving clinical benefit; documentation may be requested.

Continuation of Entyvio: If patient is currently receiving Entyvio and is receiving benefit from therapy, no further form questions are required. Chart notes or medical record documentation supporting benefit must be submitted upon request.

If not receiving benefit, the form still indicates no further questions, but documentation may be requested for review

Step Therapy Verification

Question	Required provider response / documentation
Has the patient had an inadequate response or intolerance to systemic corticosteroids or infliximab?	Select Yes or No. If Yes: indicate prior agent(s) tried and provide chart notes, medical record documentation, or claims history supporting the previous medications tried and the patient’s response (these must be submitted upon request). If No: continue to contraindication question (see next row).
Does the patient have a contraindication to systemic corticosteroids or infliximab?	Select Yes or No. If Yes: provide the clinical reason in the space provided on the form; documentation of the clinical reason must be submitted upon request (a clinician reviewer will evaluate the rationale). If No: document accordingly.

Dispense and Administration Site

Note

Select dispensing and administration site from listed options

Indicate on the form both where the drug will be dispensed and where it will be administered by selecting the appropriate option(s) from the listed site-of-care choices (e.g., Office, Outpatient Hospital, Pharmacy, Home, etc.).

Dispensing location: choose from the provided list (Office; Outpatient Hospital; Ambulatory Surgical; Pharmacy; Other, etc.).
Administration site: choose from the provided list (Ambulatory surgical; Home; Inpatient Hospital; Office; Outpatient Hospital; Pharmacy).

Condition Definitions

inv-11: Ulcerative colitis (moderately to severely active)

IndicationModerately to severely active ulcerative colitis

Form flowIf selected, continue to question #2 on the form to establish current Entyvio use

Documentation requirementIf patient is currently receiving Entyvio and is receiving benefit, chart notes or medical record documentation supporting benefit must be submitted upon request

Other selectionIf 'Other' is selected instead, the form indicates 'No Further Questions' for this pathway

inv-12: Crohn's disease (moderately to severely active)

IndicationModerately to severely active Crohn's disease

Form flowIf selected, continue to question #2 on the form to establish current Entyvio use

Documentation requirementIf patient is currently receiving Entyvio and is receiving benefit, chart notes or medical record documentation supporting benefit must be submitted upon request

Other selectionIf 'Other' is selected instead, the form indicates 'No Further Questions' for this pathway

inv-13: Immune checkpoint inhibitor-related toxicity

IndicationImmune checkpoint inhibitor-related toxicity

Initial therapy requirementForm asks whether the patient had an inadequate response or intolerance to systemic corticosteroids or infliximab; if yes -> No Further Questions

If no prior failureIf no inadequate response/intolerance, form asks whether the patient has a contraindication to systemic corticosteroids or infliximab and requests clinical reason if present

DocumentationChart notes, medical record documentation, or claims history supporting previous medications tried and response to therapy must be submitted upon request

Background and Intended Use

This prior authorization form is intended for use when prescribing therapies (notably Entyvio/vedolizumab) for patients with moderately to severely active ulcerative colitis, moderately to severely active Crohn's disease, or for management of immune checkpoint inhibitor–related toxicity. The form solicits whether the patient is currently receiving Entyvio and whether they are deriving clinical benefit, and for the checkpoint inhibitor toxicity pathway it asks about prior inadequate response or intolerance to systemic corticosteroids or infliximab and/or documented contraindications.

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