CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization form for specialty/infused medications

Tool and requirements for providers to request prior authorization from CVS Caremark (on behalf of HMSA) for certain prescription or specialty medications; applies to prescribing providers and infusion/dispensing sites for HMSA members.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization form for specialty/infused medications

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the CVS Caremark prior authorization form to 1-866-237-5512 with diagnosis (ICD-10), patient demographics, site of care, and requested clinical details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-800-237-2767CaremarkConnect phone

1-866-237-5512Prior auth fax

ICD-10 requestedICD-10 requested

30Opt-out honor timeframe (days)

Coverage Criteria

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Authorization decision criteria (form-driven)

Form asks for criteria to determine authorization based on brand vs generic use and specific clinical indications.

Stem cell mobilization / Gene therapy pathway: If the request is not for a brand (or after completing brand/generic questions), the form asks whether the medication will be used to mobilize hematopoietic stem cells; whether it will be administered after granulocyte-colony stimulating factor (e.g., Neupogen) or chemo-mobilization; and whether it is part of a gene therapy protocol. Responses to these items inform the authorization decision.

Questions 5–7 on the form

Duration after harvest: The form asks whether the medication will be used beyond 4 consecutive days or after completion of stem cell harvest/apheresis; this information is collected to inform authorization and site-of-care considerations.> 4 consecutive days

Question 8 on the form

The prior authorization form does not list any explicit medication exclusions on its face. Instead, coverage decisions rely on answers and supporting documentation provided on the form — particularly when the request follows the brand vs. generic pathway. In practice, incomplete or missing documentation (for example, failure to provide the detailed chart documentation requested when a generic trial failed for an intolerable adverse event) can prevent the reviewer from making a coverage determination and may result in denial or delay of authorization.

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Providers must submit a completed CVS Caremark prior authorization form and fax it to CVS Caremark toll-free at 1-866-237-5512. Include the most accurate ICD-10 diagnosis code, patient demographics (name, DOB, ID, contact), prescribing clinician details (name, NPI, specialty, office phone/fax), and relevant clinical information (weight, height, site of administration/dispense, and indication). For questions about prior authorization call CVS Caremark at 1-808-254-4414; for Specialty Customer Care call CaremarkConnect 1-800-237-2767.

Fax: 1-866-237-5512
CVS Caremark prior authorization form must be fully completed
Include ICD-10 diagnosis and patient demographics
Provide clinician name, NPI, office phone/fax

Step Therapy

Step/Brand vs Generic Verification

The prior authorization form specifically asks whether the request is for a brand-name product and whether the patient failed the generic due to an intolerable adverse event. Indicate clearly on the form if the request is for a brand and answer the step/brand verification questions.

Question: Is the request for a brand name medication?
Document whether patient failed generic due to intolerable adverse event

Documentation Required

Required Supporting Documentation for Adverse Event

If the generic trial failed because of an intolerable adverse event, you must provide specific and detailed supporting documentation with the submission. Acceptable documentation includes chart notes describing the adverse event, dates and times, severity, attribution to the active ingredient, dosage and duration of the generic medication trial, any required interventions, and relevant test or laboratory results. A MedWatch form documenting the adverse reaction may also be submitted.

Provide detailed chart documentation: description, date/time, severity, attribution to active ingredient
Include dosage and duration of generic treatment and any interventions
Attach relevant tests/labs or MedWatch form

Denial Risk

Denial Triggers

Failure to fax the completed CVS Caremark prior authorization form, failure to provide an accurate ICD-10 diagnosis, or failure to supply required documentation of a generic trial and intolerable adverse event may result in denial of the request. Ensure all required fields are completed and supporting records are available for review.

Denial triggers: incomplete form or not faxed to 1-866-237-5512
Denial triggers: missing/incorrect ICD-10 diagnosis
Denial triggers: absent or insufficient documentation of generic trial/adverse event

Step	Requirement	Provider action / documentation	Coverage label
1
If the request is for a brand-name medication, provider must document prior trial with the generic and whether it failed due to an intolerable adverse event.
Answer form question 2: indicate whether patient failed generic due to an intolerable adverse event (examples: rash, nausea, vomiting).
covered_with_criteria

Background

This authorization form is used to support coverage decisions for prescription and specialty medications, including indications where the agent is used to mobilize hematopoietic stem cells or is given after granulocyte‑colony stimulating factor (G‑CSF) or chemo‑mobilization, and for medications given as part of gene therapy protocols. The form collects clinical details (brand vs. generic use, whether a generic trial failed because of an intolerable adverse event, and whether that adverse event was documented) and asks providers to indicate the intended administration/dispensing site and duration of use to inform the authorization review.

Definitions

Intolerable adverse event — definition and examples

DefinitionAn adverse event (e.g., rash, nausea, vomiting) attributed to the generic medication that is intolerable to the patient and may justify use of a brand medication.

ExamplesRash; nausea; vomiting (examples listed on the form as intolerable adverse events).

Documentation requiredSpecific and detailed chart documentation including description, date/time, severity, dosage and duration of generic treatment, required interventions, and relevant tests/laboratory data, or a MedWatch form.

CausalityEvent must be attributed to the generic medication and, when asked, whether it is an expected adverse event for the active ingredient per prescribing information.

Role in decision-makingIf a patient failed a generic due to an intolerable adverse event, the form uses this information to determine eligibility for brand medication approval (brand-versus-generic pathway).

OpenPayer

Prior authorization form for specialty/infused medications

Coverage Criteria

Diagnosis and Coding

Provider Actions and Submission Requirements

Step Therapy Requirements

Site of Care / Dispensing and Administration

Background

Definitions