CurrentHawaii Medical Service Association (HMSA)Policy N/A

HMSA Medicare Advantage - Prior Authorization Request

A prior authorization request form used by CVS Caremark for HMSA Medicare Advantage members to request coverage for certain medications (examples: Epoprostenol, Flolan, Veletri). The form collects patient/provider demographics, site of care, diagnosis (ICD-10), and a branched question set to support initial and continuation coverage decisions for diagnoses including pulmonary arterial hypertension, angina pectoris, and peripheral vascular disease.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHMSA Medicare Advantage - Prior Authorization Request

Policy CodePolicy N/A

Change TypeClarified (footer/contact/form ID)

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Form references Epoprostenol, Flolan, Veletri and includes CMS/Caremark contact and fax numbers with form ID and date code 'HMSAMED C26858-A - 01/2026'.

3Primary diagnosis branches

1Mean PA pressure threshold

2Sites of care sections (dispense/admin)

Policy summary & scope

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CVS Caremark administers the prescription benefit plan for HMSA Medicare Advantage. This prior authorization request form collects patient and provider demographics, site of care, ICD-10 diagnosis, and a branched set of clinical and administrative questions to support a coverage determination for certain specialty medications (examples: Epoprostenol — Flolan, Veletri). Payer: HMSA; Form: HMSA Medicare Advantage - Prior Authorization Request; Status: CURRENT. Fax submissions and contact numbers for CVS Caremark are provided on the form for prior authorization processing and member/provider inquiries.

Initial and continuation therapy decision logic

Initial Therapy / Prior Authorization Decision Branching

Complete the form and answer branching questions; responses guide coverage determination.

Diagnosis selection (one of)

Pulmonary arterial hypertension (PAH)
Continue to #10
Angina pectoris
Continue to #2
Peripheral vascular disease (e.g., Raynaud's disease, thrombotic angiopathy)
Continue to #2
Other
No Further Questions

Therapy status branching

ANY of the following
- answer: Yes
  Continue to #3
- answer: No
  Continue to #20
ANY of the following
- answer: Yes
  Continue to #4
- answer: No

Continuation (if currently receiving therapy)

Diagnosis for continuation
- Angina pectoris
  Continue to #5
- Peripheral vascular disease (PVD)
  Continue to #6
Benefit from therapy (one of)
- Yes
  No Further Questions
- No
  No Further Questions

Pulmonary arterial hypertension (PAH) criteria branching

ANY of the following
- Yes
  Continue to #11
- No
  Continue to #11
ANY of the following
- Yes
  No Further Questions
- No
  Continue to #12
ANY of the following

Angina pectoris / Peripheral vascular disease initial path

Angina pectoris
No Further Questions (#20)
Peripheral vascular disease (e.g., Raynaud's disease, thrombotic angiopathy)
No Further Questions (#20)

The PAH branch uses a numeric hemodynamic threshold: mean pulmonary artery pressure must be > 25 mmHg at rest or > 30 mmHg with exertion to meet the criterion in the prior authorization decision pathway.

Required actions & documentation

Prior Authorization

Submit completed PA form to CVS Caremark

Fax the completed prior authorization form to CVS Caremark Specialty Programs at 1-866-237-5512. Provide supporting documentation upon request to assist the coverage determination.

Fax: 1-866-237-5512
Form ID/date: HMSAMED C26858-A - 01/2026

Documentation Required

Provide diagnosis and supporting documentation

Provide the most accurate diagnosis and the ICD-10 code, patient demographics, site of care, weight and height, and answer the clinical branching criteria. Attest that documentation supporting the provided information is available for review if requested by CVS Caremark or the benefit plan sponsor.

Denial Risk

Approval may be subject to dosing limits

Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines; this condition may limit coverage or lead to denial if dosing exceeds those limits.

OpenPayer

HMSA Medicare Advantage - Prior Authorization Request

Policy summary & scope

Initial and continuation therapy decision logic

Diagnosis / billing codes

Required actions & documentation

Definitions

Document changes & notes