CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization form for specialty biologic and targeted synthetic therapies for psoriasis, psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis

This document is a CVS Caremark prior authorization request form used by HMSA to evaluate coverage for specialty biologic and targeted synthetic drugs for plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis. It governs prior authorization submission requirements and clinical questions providers must answer to determine medical necessity.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization form for specialty biologic and targeted synthetic therapies for psoriasis, PsA, AS, nr-axSpA

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Indications

MultiplePrior-therapy checkpoints

RequiredTB screening

Phone/fax includedCaremark contacts

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Plaque psoriasis - Initial and continuation

Covered when the following grouped criteria are met for plaque psoriasis requests

Age and diagnosis: Patient diagnosed with moderate to severe plaque psoriasis and age >=6 years for applicable productsage >= 6 years

questions 100-102

Continuation of therapy: If continuation request, patient must have documented positive clinical response or improvement in signs/symptoms or reduced BSA compared to baselineN/A

questions 103-107

Prior biologic or targeted synthetic use: If patient has ever received or is currently receiving an indicated biologic or targeted synthetic for psoriasis (excluding samples/PAP), no further questions (prior use satisfies initial criteria)N/A

question 108

Prior conventional therapy or severity features: For initial therapy when no prior biologic: either crucial body areas are affected OR BSA >= 3% OR inadequate response/intolerance to phototherapy or systemic agents (methotrexate, cyclosporine, acitretin) OR clinical reason to avoid these agentsBSA >= 3%

questions 109-114

Psoriatic arthritis - Initial and continuation

Covered when the following grouped criteria are met for psoriatic arthritis requests

Diagnosis: Patient diagnosed with active psoriatic arthritisN/A

question 210

Continuation of therapy: If continuation request, evidence of maintained clinical response such as improvement in swollen/tender joint counts, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, or CRPN/A

questions 202-205

Prior biologic or targeted synthetic use: If patient has ever received or is currently receiving an indicated biologic or targeted synthetic for PsA (excluding samples/PAP), no further questionsN/A

Axial spondyloarthritis - Initial and continuation

Covered when grouped criteria are met for axial spondyloarthritis requests

Diagnosis and specialty consult: Patient diagnosed with active ankylosing spondylitis or active non-radiographic axial spondyloarthritis; requested by or in consultation with a rheumatologistN/A

questions 300-301,306

Continuation of therapy: If continuation request, evidence of maintained clinical response such as improvement in functional status, spinal pain, inflammation, swollen/tender joints, or CRPN/A

questions 302-305

NSAID trial requirement: For initial therapy, inadequate response to at least TWO NSAIDs, or intolerance/contraindication to at least two NSAIDs>=2 NSAIDs tried

Tuberculosis screening and management

TB screening and management required prior to initiation

TB screening and management: Assess prior use of biologic/targeted agents associated with TB risk; perform TB test (TST or IGRA) within 12 months of initiating therapy; document test result (positive/negative/unknown) and indicate latent or active TB treatment statusTB test within 12 months

questions 1-5

If the selected diagnosis is Other (i.e., not one of the form’s listed indications: plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, or non-radiographic axial spondyloarthritis), the form instructs No Further Questions. This indicates the prior-authorization form does not provide evaluative criteria for unlisted diagnoses and completion of the form will not proceed to condition-specific clinical checkpoints.

The form requires documentation of specific prior-therapy trials or reasons for not having tried those therapies before an initial approval can be granted. Examples include: for plaque psoriasis, prior receipt of an indicated biologic/targeted synthetic drug or evidence of inadequate response/intolerance to phototherapy or systemic agents, or involvement of crucial body areas or BSA ≥ 3%; for psoriatic arthritis, inadequate response or intolerance to conventional synthetic DMARDs (e.g., methotrexate, leflunomide, sulfasalazine) or documented contraindication; and for ankylosing spondylitis/nr-axSpA, inadequate response to at least two NSAIDs (or intolerance/contraindication to two NSAIDs). Requests missing this required prior-therapy evidence (or documentation of intolerance/contraindication) do not meet the form’s criteria for initial coverage and therefore would be considered not medically necessary per the form logic.

Initial Therapy Criteria

Initial therapy requirements — trials of prior therapies or severity features depending on indication

Initial therapy requires evidence of prior therapy trials or presence of specific severity features depending on indication

Psoriasis initial: Either prior biologic/targeted use OR crucial body areas affected OR BSA >= 3% OR inadequate response/intolerance to phototherapy or systemic agents, or clinical reason to avoid those agentsSee BSA thresholds

questions 108-114

PsA initial: Diagnosis of active PsA AND inadequate response or intolerance to a conventional synthetic DMARD (e.g., methotrexate, leflunomide, sulfasalazine) OR contraindication to these agents; enthesitis or predominately axial disease may satisfy criteria without csDMARD failureN/A

questions 211-218

AS/nr-axSpA initial: Diagnosis of active AS or nr-axSpA AND inadequate response to at least two NSAIDs or intolerance/contraindication to at least two NSAIDs>=2 NSAIDs tried

questions 306-308

Indication / Step	Prior therapy required or alternative (trial or documentation of intolerance/contraindication)	If prior biologic/targeted synthetic used
Plaque psoriasis — initial therapy	Either: trial of phototherapy or systemic agents (methotrexate, cyclosporine, acitretin) with inadequate response OR clinical reason to avoid these agents OR involvement of crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) OR BSA ≥ 3% (with ≥3%–<10% or ≥10% captured)	If the patient has ever received or is currently receiving a biologic or targeted synthetic indicated for plaque psoriasis (excluding samples/PAP): no further prior-therapy questions — proceed (meets requirement)
Psoriatic arthritis — initial therapy	Inadequate response or intolerance to a conventional synthetic DMARD (e.g., methotrexate, leflunomide, sulfasalazine) given at adequate dose and duration, or documented contraindication to these agents; presence of enthesitis or predominately axial disease or severe disease may obviate further trials	If the patient has ever received or is currently receiving a biologic or targeted synthetic indicated for PsA (excluding samples/PAP): no further prior-therapy questions — proceed (meets requirement)
Ankylosing spondylitis / non-radiographic axial spondyloarthritis — initial therapy	Inadequate response to at least TWO NSAIDs, or intolerance/contraindication to at least two NSAIDs	If the patient has ever received or is currently receiving a biologic or targeted synthetic indicated for AS or nr-axSpA (excluding samples/PAP): no further prior-therapy questions — proceed (meets requirement)

Continuation Therapy Criteria

Continuation therapy requirements — documented maintained benefit since starting the requested drug

Continuation requests require documented maintained benefit since starting the requested drug

Psoriasis continuation: Documented positive clinical response or reduction in BSA or improvement in signs/symptoms since starting treatmentN/A

questions 103-107

PsA continuation: Documented improvement in swollen/tender joints, dactylitis, enthesitis, axial disease, skin/nail involvement, function, or CRP since starting treatmentN/A

questions 202-205

AS/nr-axSpA continuation: Documented improvement in functional status, spinal pain, inflammation, joint signs, or CRP since starting treatmentN/A

questions 302-305

Continuation of therapy — required evidence

Required evidence for continuation (actionable)For continuation requests, provider must document maintained positive clinical response or low disease activity since starting the requested drug (question 105) — e.g., sustained improvement in signs/symptoms or reduced BSA

BSA reduction assessmentContinuation question 106 asks whether the patient experienced a reduction in body surface area affected from baseline; a 'Yes' yields no further questions

Symptom improvement assessmentQuestion 107 asks whether the patient experienced improvement in signs/symptoms (itching, redness, flaking, scaling, burning, cracking, pain); a 'Yes' yields no further questions

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Submission

Prior authorization is required for coverage of specialty medications. To request prior authorization, complete the HMSAMCD Prior Authorization Request form and fax it to CVS Caremark Specialty Programs at 1-866-237-5512. Questions about prior authorization may be directed to CVS Caremark at 1-808-254-4414. For eligibility, copay, or delivery inquiries contact CaremarkConnect® at 1-800-237-2767.

Send completed form to CVS Caremark Specialty Programs via fax: 1-866-237-5512
Include most accurate diagnosis and patient identifiers (name, ID, DOB, phone)
Approvals may be subject to dosing limits per FDA labeling, compendia, or evidence-based guidelines

Step Therapy

Prior‑therapy Evaluation

The prior-therapy evaluation section of the form documents prior use of biologic or targeted synthetic therapies and documents required step-therapy or contraindications. Providers must complete all applicable prior-therapy questions (e.g., prior biologic/targeted synthetic use, prior response or intolerance to conventional therapies, prior phototherapy) to support medical necessity for the requested agent.

Document whether patient has ever received or is currently receiving a biologic or targeted synthetic agent (exclude samples or patient assistance program supplies)
Record prior therapies tried, inadequate responses, intolerances, or clinical reasons to avoid conventional agents (e.g., methotrexate, leflunomide, cyclosporine, acitretin)
For dermatologic indications, document body surface area (BSA) and involvement of crucial body areas when applicable

Documentation Required

Attestation and Supporting Documentation

The prescriber (or authorized signer) must attest that the information provided is accurate and that supporting documentation is available for review by CVS Caremark or the benefit plan sponsor. Keep all clinical records, prior therapy documentation, and rationale for contraindications or intolerance available in case of audit or review.

Signed attestation required: Prescriber or authorized signature and date
Maintain documentation of prior treatments, clinical assessments (e.g., functional status, CRP, swollen/tender joints), and reasons for therapy selection or avoidance
Documentation must be available upon request by CVS Caremark or the plan sponsor

Denial Risk

Submission Requirement and Risk of Denial

Failure to submit the completed prior authorization form and any required supporting documentation to CVS Caremark at the listed fax number or to contact the prior authorization helpline may result in delayed processing or denial of coverage.

Incomplete forms or missing prior-therapy/attestation information may result in denial or request for additional information
Fax number for submission: 1-866-237-5512; Phone inquiries: 1-808-254-4414

OpenPayer

Prior authorization form for specialty biologic and targeted synthetic therapies for psoriasis, psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis

Coverage Criteria

Coding and Severity Thresholds

Initial Therapy Criteria

Continuation Therapy Criteria

Provider Actions and Submission Requirements

Dispensing and Administration Site

Definitions and Examples

Background