CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization request form for specialty/covered medications

This prior authorization request form (administered by CVS Caremark on behalf of HMSA) collects clinical and administrative information to determine coverage for certain prescription and specialty medications, affecting prescribing providers and pharmacies seeking prior authorization under the member's prescription benefit.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization request form for specialty/covered medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form and supporting documentation to CVS Caremark at 1-866-237-5512 for determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number for submission

1-800-237-2767CaremarkConnect phone

8decision flow questions

multiplesite-of-care options

Coverage Criteria

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Prior authorization decision flow

Form contains decision logic; coverage determinations depend on answers and supporting documentation.

Brand medication request pathway: If the request is for a brand name medication: 1) determine whether the patient failed treatment with the generic medication due to an intolerable adverse event (e.g., rash, nausea, vomiting); 2) determine whether the intolerable adverse event was an expected adverse event attributed to the active ingredient as described in the prescribing information; 3) confirm the adverse event was documented in the patient chart and require SPECIFIC and DETAILED chart documentation including description, date/time, severity of the adverse event, dosage and duration of generic medication treatment, required intervention (if any), and relevant tests or laboratory data OR a MedWatch form; prescriber attestation/signature required.

Answers to these questions direct continuation through the form

Stem cell mobilization pathway: If the requested medication will be used to mobilize hematopoietic stem cells: ask whether it will be administered after granulocyte‑colony stimulating factor (e.g., Neupogen) or after chemo‑mobilization; ask whether it will be administered as part of a gene therapy protocol; and ask whether it will be used beyond 4 consecutive days or after completion of stem cell harvest/apheresis. Responses inform authorization review.

Questions 5–8

Non-brand or other uses: If the request is not for a brand name medication and the medication will not be used to mobilize hematopoietic stem cells, no further form questions are required and standard prior authorization processing applies.

Decision flow ends at question 5 if No

The form does not include an explicit list of clinical exclusions. It requests the ICD-10 code for the submitted diagnosis but does not enumerate any diagnoses or conditions that would be automatically excluded from consideration.

The form itself does not define specific scenarios that are categorically not medically necessary. Instead, coverage decisions are determined through the responses to the form’s clinical questions and the supporting documentation provided (for example, detailed chart notes or a MedWatch form when applicable). Authorization reviewers rely on the documented clinical rationale and submitted evidence to determine medical necessity.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain specialty medications administered under the patient's CVS Caremark benefit. Submit the completed HMSACOM Prior Authorization Request form and all supporting clinical documentation by fax to CVS Caremark toll-free at 1-866-237-5512. For prior-authorization questions contact CVS Caremark at 1-808-254-4414; for benefit/cost/delivery questions contact CaremarkConnect 1-800-237-2767.

Fax: 1-866-237-5512
PA questions: 1-808-254-4414
CaremarkConnect (benefit/cost/delivery): 1-800-237-2767

Note

Complete Embedded Clinical Decision Questions on the Form

The prior-authorization form contains embedded clinical decision questions the provider must complete. These include whether the request is for a brand product, documentation of failure or intolerance to the generic, attribution of the adverse event to the active ingredient, and questions about use for stem cell mobilization, post–G-CSF or chemo-mobilization administration, and use in gene therapy protocols.

Brand vs generic flow (Questions 1–4)
Adverse event attribution and chart documentation prompts (Questions 2–4)
Stem cell mobilization and related use questions (Questions 5–8)

Documentation Required

Detailed Adverse Event Documentation Required for Brand Requests

When requesting a brand medication after an adverse event or intolerance to the generic, provide SPECIFIC and DETAILED chart documentation. Required details include description of the adverse event, date/time and severity, dosage and duration of the generic trial, any interventions required, and relevant laboratory or test data. A MedWatch form documenting the trial and failure may be submitted if applicable.

Describe the adverse event (signs/symptoms) with date/time and severity
Document generic medication dose, duration, and any treatment interventions
Include relevant labs/tests or a completed MedWatch form

Documentation Required

Documentation and Dosing Limits

Provide the most accurate diagnosis and supporting clinical documentation for the prescribed medication. Approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.

Accurate diagnosis and supporting chart notes required
Approvals may include dosing limits per FDA labeling/compendia/guidelines

Definitions

Intolerable adverse event — definition & required documentation

DefinitionAn 'intolerable adverse event' is an adverse event (e.g., rash, nausea, vomiting) that led to failure of the generic medication and must be documented with specifics including description, date/time, and severity of the adverse event, dosage and duration of the generic medication treatment, required interventions (if any), and relevant tests or laboratory data (if any).

Required documentationProvide SPECIFIC and DETAILED chart documentation OR a MedWatch form of the trial and failure including the adverse reaction when requesting brand after generic intolerance; prescriber attestation required on the form.

Examples of qualifying eventsIllustrative examples listed in the form include rash, nausea, and vomiting as intolerable adverse events prompting documentation when generic failed.

Attribution assessmentForm asks whether the intolerable adverse event was an expected adverse event attributed to the ACTIVE ingredient as described in the prescribing information (i.e., known adverse reaction for both brand and generic).

Next steps in decision flowIf an intolerable adverse event is reported, the form requires documentation per item #4 and then continues through the authorization questions (see subsequent stem cell and gene therapy questions).

Requirement	Details
When requesting a brand medication after documented failure or intolerance to a generic	Provide specific and detailed chart documentation describing the adverse event (description, date/time, severity), dosage and duration of the generic treatment, required interventions and relevant tests/labs, and prescriber signature and date. Alternatively, submit a MedWatch form documenting the adverse event.

Background

The prior authorization form collects clinical details that inform medication selection, including whether the request is for a brand name medication and whether the patient experienced an intolerable adverse event (examples given: rash, nausea, vomiting) with a generic product. When a brand is requested after generic intolerance, the form requires indication whether the event was expected for the active ingredient and whether the event was documented in the chart, with instructions to provide specific and detailed chart documentation or a MedWatch form. The form also captures high-acuity use by asking whether the medication will be used for hematopoietic stem cell mobilization, including follow-up questions about prior granulocyte‑colony stimulating factor or chemo‑mobilization, gene therapy protocols, and use beyond 4 consecutive days. Additionally, the form collects basic administration and dispensing site information (e.g., office, outpatient hospital, home, pharmacy).

OpenPayer

Prior authorization request form for specialty/covered medications

Coverage Criteria

Coding

Provider Actions & Submission Requirements

Definitions

Step Therapy Requirements

Site of Care

Background