CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSA Medicare Advantage - Prior Authorization Request

A fillable prior authorization (PA) request form administered by CVS Caremark on behalf of HMSA Medicare Advantage for certain colony stimulating factor (CSF) short-acting products (Granix, Leukine, Neupogen, Nivestym, Releuko, Zarxio). The form collects patient/provider info, site of care, ICD-10, drug selection, and branching clinical questions to determine PA approval, documentation requirements, and substitution to preferred product Zarxio.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSA Medicare Advantage - Prior Authorization Request

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed PA form to CVS Caremark at 1-866-237-5512 or call 1-808-254-4414 for inquiries; attach supporting chart notes when required and include ICD-10 and site of care information.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form content and coverage requirements remain unchanged.

6Drugs listed on form

365Lookback period (days)

180Dose threshold (mcg)

Policy overview

CVS Caremark administers the prescription benefit for HMSA Medicare Advantage and requires prior authorization for certain short-acting colony stimulating factor (CSF) products. The fillable PA form operationalizes PA determinations for short-acting CSFs and biosimilars and collects patient and provider information, site of care, ICD-10 code, and drug selection with branching clinical questions to determine prior authorization, documentation requirements, and substitution to the plan-preferred product.

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Thresholds and key stats

Drugs listed on form6

Lookback period for prior use365 days

Dose threshold180 mcg

Scope summaryA fillable prior authorization (PA) request form administered by CVS Caremark on behalf of HMSA Medicare Advantage for certain colony stimulating factor (CSF) short-acting products (Granix, Leukine, Neupogen, Nivestym, Releuko, Zarxio). The form collects patient/provider info, site of care, ICD-10, drug selection, and branching clinical questions to determine PA approval, documentation requirements, and substitution to preferred product Zarxio.

Prior authorization criteria (form logic)

General Branching PA Questions

Complete applicable questions based on requested product to determine PA; follow branching instructions.

Product-specific branches

Zarxio preferred-product shortcut
- Identify drug being prescribed (choices: Granix, Leukine, Neupogen, Nivestym, Releuko, Zarxio)
- Zarxio answer: Preferred product is Zarxio; can patient switch to Zarxio?
  Answer options: Yes — No further questions; No — continue to product-specific branch.
Granix/Neupogen/Nivestym/Releuko branch
- Q4
  - Q4 - Yes: Yes — No further questions.
  - Q4 - No: No — continue to product-specific pathway (Q5)
- Q5
  - Q5 - Yes: Yes — Attach supporting chart note(s); No further questions.
    Attach supporting chart notes
  - Q5 - No: No — continue to Q6
- Q6
  - Q6 - Yes: Yes — Attach supporting chart note(s); No further questions.< 180 mcg
    Attach supporting chart notes
  - Q6 - No: No — continue to Q7
- Q7
  - Q7 - Yes: Yes — Attach supporting chart note(s); continue to Q8
    Attach supporting chart notes
  - Q7 - No: No — No further questions
    Attach supporting chart notes
- Q8
  - Q8 - Yes: Yes — No further questions.
  - Q8 - No: No — Attach supporting chart note(s); No further questions.
    Attach supporting chart notes
Leukine branch
- Q9
  - Q9 - Yes: Yes — Attach supporting chart note(s); No further questions.past 365 days
    Attach supporting chart notes
  - Q9 - No: No — continue to Q10
- Q10
  - Q10 - Yes: Yes — Attach supporting chart note(s); No further questions.
    Attach supporting chart notes

ref

Required codes and form fields

ICD-10 field (form asks for code)ICD-10

No codes listed

Required fields on the form include an ICD-10 diagnosis code, indication of where the drug is being dispensed and where it will be administered (site of care), selection of the requested product from the listed drugs, and a prescriber or authorized signature with date attesting to accuracy and availability of supporting documentation.

The form also requests additional documentation (e.g., supporting chart notes) in specified situations per the branching questions, and asks for basic patient demographic details (e.g., weight) used for processing.

What providers must do

Prior Authorization

Submit completed PA form to CVS Caremark Specialty Programs

Fax the completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512 (specialty). For PA inquiries, contact CVS Caremark at 1-808-254-4414.

Documentation Required

Attach supporting chart notes for specified criteria

When patient has a documented latex allergy requiring latex-free vials (Neupogen pre-filled syringes contain latex and are not covered under this criterion).
When patient has an intolerable adverse event to the preferred product (Zarxio).
When patient has an inadequate response to the preferred product (Zarxio).
When Leukine is requested for an indication that is not FDA-approved for the preferred product.

Billing Rule

Provide accurate diagnosis and site of care

Provide the accurate ICD-10 diagnosis code, indicate the patient/site of care and where the drug will be administered on the form so coverage and processing can be determined.

Documentation Required

Provider attestation and signature

The prescriber or an authorized signer must sign and date the form attesting that the information is accurate and that supporting documentation is available for review by CVS Caremark or the plan sponsor.

Definitions & notes

Definitions

Preferred productZarxio is identified on the form as the plan-preferred product to which substitution is requested where appropriate.

Operationally, approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines as noted on the form.

The form operationalizes PA determinations for short-acting CSFs and biosimilars, including pathways for substitution to the preferred product Zarxio and documentation requirements for prior use, inadequate response, intolerable adverse events, and certain dose-based or latex-allergy exceptions.

The form specifically notes that Neupogen pre-filled syringes contain latex and are not covered under the latex-free vial criterion, so requests relying on the latex-free vial criterion must account for this exception.