Global Medicare Advantage Medical Prior Authorization Request (Specialty Drugs Coverage Criteria)
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Form and criteria used by CVS Caremark on behalf of HMSA to collect information and authorize coverage for certain specialty medications for Medicare Advantage members; affects prescribers seeking drug coverage under the medical or pharmacy benefit.
No material clinical or coverage changes in this revision.
Coverage Criteria and Routing
Global criteria for approval
Global criteria and routing questions used to determine approval
routes workflow based on drug
determines benefit channel
used in review
affects documentation and prior authorization
checks prior approvals
drug-specific branch
supports continuation approvals
required for authorization
If the provider indicates No to the buy-and-bill question (Q51), the prior authorization request is closed and the request is redirected to the pharmacy benefit. The form specifies that the drug is only covered under Medicare Part B when administered under the direct supervision of a physician. If Q51 is answered Yes, continue processing per the medical benefit pathway (proceed to Q101).
Diagnosis and Billing Codes
| ICD-10 | What is the ICD-10 code? (field provided on form) |
Provider Actions and Submission Requirements
Prior Authorization Submission
Prior authorization is required for certain specialty medications. Submit the completed prior authorization request form and all required documentation to CVS Caremark Specialty Programs via fax at 1-866-237-5512. Questions about the prior authorization decision may be directed to CVS Caremark at 1-808-254-4414. Approvals may be subject to dosing limits consistent with FDA labeling, accepted compendia, and evidence-based practice guidelines.
- Fax: 1-866-237-5512 (CVS Caremark Specialty Programs)
- PA questions/inquiries: 1-808-254-4414
- Specialty Customer Care (eligibility/copay/delivery): CaremarkConnect® 1-800-237-2767
- Approvals may be subject to dosing limits per FDA labeling/compendia/guidelines
Drug-specific Routing (Ajovy / Takhzyro)
Use the triage question (#50) to identify drug-specific routing. If the request is for Ajovy or Takhzyro and question 50 is answered Yes, continue to question 51 to determine buy-and-bill handling. If question 50 is No, follow standard routing (continue to #101).
- Question 50: Is the request for Ajovy or Takhzyro? If Yes → continue to #51. If No → continue to #101.
- Question 51: Is the physician requesting buy-and-bill? If Yes → continue to #101. If No → close PA and redirect to pharmacy benefit (drug covered under Part B only when administered under direct physician supervision).
Required Documentation
Authorization requests must include supporting clinical documentation. Attach current chart notes, office visit notes, and applicable studies that substantiate the diagnosis and evidence of response to therapy when applicable.
- Required: Chart notes or clinical information supporting the diagnosis
- Required: Proposed treatment plan
- If requesting continuation of therapy, include documentation of prior authorization or evidence of response to treatment (e.g., office notes, studies)
Supporting Clinical Documentation
Provide all supporting clinical documentation with the PA submission to demonstrate medical necessity and response to therapy. CVS Caremark may request these records for review and decisions may be contingent on the information supplied.
- Attach current clinical documentation (office visit notes, applicable studies) to support response to treatment per question 105
- The prescriber must attest that documentation is available for review if requested by CVS Caremark or the benefit plan sponsor
- Send completed form and attachments to CVS Caremark Specialty Programs via fax: 1-866-237-5512
Ajovy / Takhzyro and Buy-and-Bill Routing Summary
Summary: Requests for Ajovy or Takhzyro are routed based on the response to question 50. If buy-and-bill is not requested (question 51 = No), the PA is closed and the request is redirected to the pharmacy benefit. If buy-and-bill is requested (question 51 = Yes), continue processing under Part B routing. Ensure required documentation and signatures accompany the submission.
- If question 50 = Yes (Ajovy/Takhzyro) → answer question 51 to determine buy-and-bill routing
- If question 51 = No → close PA and redirect to pharmacy benefit (drug only covered under Part B when administered under direct physician supervision)
- If question 51 = Yes → proceed with buy-and-bill handling and continue to global criteria (#101 and onward)
- Ensure prescriber signature and attestation are included on the form
Initial Therapy (New Start) Criteria
Initial therapy
New start pathway
required for initial authorization
Continuation of Therapy Criteria
Continuation of therapy
Continuation of therapy pathway
supports ongoing authorization
ensures correct benefit channel
Step Therapy and Routing Logic
| Question | Routing / Action |
|---|---|
| Q50: Is this request for Ajovy or Takhzyro? | If Yes → continue to Q51. If No → continue to Q101 (follow standard workflow). |
| Q51: Is the physician requesting the drug for buy-and-bill? | If Yes → continue to Q101 (consider medical benefit). If No → close PA and redirect to the pharmacy benefit. Note: drug is covered under Medicare Part B only when administered under direct physician supervision. |
Dispensing and Administration Site
Document site of care (office, infusion center, hospital outpatient, home, pharmacy, other)
Indicate the site where the drug will be dispensed and/or administered on the form; available options include office, infusion center/outpatient hospital, home, pharmacy, and other settings.
- Options listed include: Office, Outpatient Hospital/Infusion center, Ambulatory Surgical, Inpatient Hospital, Home, Pharmacy, and Other.
Definitions and Site Details
Background and Scope
This administrative prior authorization form uses triage questions to determine routing and benefit channel. Question 50 identifies whether the request is for Ajovy or Takhzyro and directs the workflow accordingly. Question 51 captures whether the physician is requesting the drug via buy-and-bill; a negative response closes the medical PA and redirects the request to the pharmacy benefit, with Part B coverage only applicable when the drug is administered under direct physician supervision.
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