CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior Authorization Request Form — Specialty Medications (Gaucher disease example)

Form and prior authorization requirements administered by CVS Caremark for HMSA Medicare Advantage members; used by prescribers to request coverage for certain prescription/specialty drugs, exemplified here for Gaucher disease therapies.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request Form — Specialty Medications (Gaucher disease example)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization to CVS Caremark (fax 1-866-237-5512) with accurate diagnosis and make diagnostic documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1disease-specific pathway shown (Gaucher disease)

2continuation vs initial sections

1fax number for PA submission

1phone number for provider questions

Coverage Criteria and Pathways

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Initial and Continuation Authorization Criteria

Coverage determination follows the form's branching logic for diagnosis, disease type, current therapy, and diagnostic confirmation.

Initial authorization for Gaucher disease: Apply when patient is not currently receiving the requested drug (Question 3 = No). Require confirmation of Gaucher disease by enzyme assay demonstrating beta-glucocerebrosidase deficiency OR by genetic testing; supporting results must be available upon request.diagnostic confirmation required

See form Question 10 for required confirmation wording

Continuation authorization for Gaucher disease: Apply when patient is currently receiving the requested drug (Question 3 = Yes). Prescriber must indicate the patient is receiving benefit from therapy (Question 4) to support continuation.treatment benefit statement

See form Question 4 for continuation assessment

Initial Authorization Criteria — Gaucher Disease

Initial - Gaucher disease

Initial authorization for Gaucher disease.

Diagnostic confirmation: Diagnosis of Gaucher disease (types 1, 2, or 3) must be confirmed by an enzyme assay demonstrating deficiency of beta-glucocerebrosidase (glucosidase) activity OR by genetic testing.

Documentation availability: If confirmed, beta-glucocerebrosidase enzyme assay or genetic testing results supporting the diagnosis must be available upon request; prescriber must attest documentation is available.

Form includes attestation statement and contact/fax information for CVS Caremark

Provider Actions, Submission, and Documentation Requirements

Prior Authorization

Submit prior authorization

Prior authorization must be requested from CVS Caremark for covered prescription/specialty medications. Fax the completed prior authorization form to CVS Caremark at 1-866-237-5512. Include accurate prescriber and drug information so an appropriate determination can be made. For questions about prior authorization, contact CVS Caremark at 1-808-254-4414. For Specialty Customer Care inquiries (eligibility, copay, delivery), contact CaremarkConnect® at 1-800-237-2767.

Fax: 1-866-237-5512
Prior auth phone: 1-808-254-4414
Specialty Customer Care: 1-800-237-2767

Note

Authorization pathway logic

The authorization form contains branching questions that require the prescriber to indicate the diagnosis and treatment status. The form asks whether the diagnosis is Gaucher disease or other; if Gaucher, the prescriber must indicate Gaucher disease type (1, 2, 3, or other). The form also asks whether the patient is currently receiving the requested drug to determine whether continuation or initial therapy questions apply.

If diagnosis = Gaucher disease → indicate type (Type 1 / Type 2 / Type 3 / Other)
If diagnosis = Other → no further questions
If currently receiving drug = Yes → continuation questions
If currently receiving drug = No → initial therapy pathway

Documentation Required

Supporting documentation availability

For initial requests the prescriber must attest that the diagnosis of Gaucher disease was confirmed by either an enzyme assay showing deficient beta-glucocerebrosidase activity or by genetic testing. The prescriber must attest that supporting documentation (enzyme assay or genetic test results) is available for review if requested by CVS Caremark or the plan sponsor.

Required confirmation methods: beta-glucocerebrosidase enzyme assay OR genetic testing
Prescriber attestation that supporting documentation will be available upon request

Denial Risk

Missing diagnostic confirmation

Failure to provide enzyme assay or genetic testing results to confirm Gaucher disease upon request may result in denial of the authorization.

Denial risk if diagnostic confirmation not provided upon request

Question	Form response options / branching
1. What is the diagnosis?
- Gaucher disease — Continue to #2 - Other — No Further Questions

Dispensing and Administration Site

Billing Rule

Specify dispensing and administration site

Indicate on the form where the drug will be dispensed and where it will be administered (choices include office, outpatient hospital, home, pharmacy, etc.) to support route- and site-specific processing.

Select dispensing site from listed options (Office, Outpatient Hospital, Pharmacy, Home, etc.)
Select administration site from listed options (Office, Inpatient Hospital, Home, Pharmacy, etc.)

Key Definitions and Diagnostic Confirmation

Enzyme assay demonstrating deficiency of beta-glucocerebrosidase or genetic testing — confirmation of Gaucher disease

Confirmatory tests acceptedEnzyme assay demonstrating deficiency of beta-glucocerebrosidase (glucosidase) enzyme activity OR genetic testing

Requirement for initial authorizationFor initial Gaucher disease requests, positive enzyme assay or genetic testing results must be available upon request to support the diagnosis

Documentation attestationPrescriber must attest that documentation supporting the diagnostic test results is available for review if requested by CVS Caremark or the benefit plan sponsor

Form response optionsForm provides checkboxes for 'Yes' or 'No' to confirm whether diagnosis was confirmed by enzyme assay or genetic testing

Contact for submission/questionsPhone: 1-808-254-4414; Fax: 1-866-237-5512 (for CVS Caremark related inquiries)