CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior Authorization Request — Specialty Medications (VPRIV / Gaucher disease)

This document is a prior authorization form used by CVS Caremark on behalf of HMSA to request coverage approval for certain prescription specialty medications (example: VPRIV for Gaucher disease). It governs requirements for prescribers to submit clinical and administrative information to determine drug coverage.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request — Specialty Medications (VPRIV / Gaucher disease)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form to CVS Caremark at 1-866-237-5512 to request approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1primary named medication example (VPRIV)

1-866-237-5512fax number to submit form

1-808-254-4414phone number for prior authorization questions

CaremarkConnect 1-800-237-2767Specialty Customer Care contact

Coverage Criteria

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior Authorization Request — Specialty Medications (VPRIV / Gaucher disease)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax the completed prior authorization form to CVS Caremark at 1-866-237-5512 to request approval.

SourceLink

On This Page

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Diagnosis confirmation

Coverage determination requires documented confirmation of Gaucher disease for the indicated diagnosis.

Diagnosis confirmation: Diagnosis of Gaucher disease must be confirmed by an enzyme assay demonstrating deficiency of beta-glucocerebrosidase or by genetic testing.

Form instructs to attach results of enzyme assay or genetic testing (action required).

Provider Actions & Submission

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization must be requested by faxing the completed HMSA/CVS Caremark prior authorization form to CVS Caremark at 1-866-237-5512. Questions regarding prior authorization may be directed to CVS Caremark at 1-808-254-4414. For inquiries related to patient eligibility, drug copay, or medication delivery, contact CaremarkConnect® Specialty Customer Care Team at 1-800-237-2767.

Fax: 1-866-237-5512
Phone (PA questions): 1-808-254-4414
CaremarkConnect (eligibility/care): 1-800-237-2767

Note

Dosing Limits

Approvals may be subject to dosing limits consistent with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines.

Documentation Required

Required Supporting Documentation

When a diagnosis confirmation for Gaucher disease is requested, attach supporting documentation: results of an enzyme assay demonstrating deficiency of beta-glucocerebrosidase enzyme activity or genetic testing showing pathogenic variants. The form asks: "Was the diagnosis of Gaucher disease confirmed by an enzyme assay ... or by genetic testing? ACTION REQUIRED: Please attach results of enzyme assay or genetic testing."

Attach enzyme assay results demonstrating beta-glucocerebrosidase deficiency when requested
Attach genetic testing results when used to confirm diagnosis

Denial Risk

Denial Risk — Missing Information or Documentation

Potential denial or delay may occur if the most accurate diagnosis is not provided, if required documentation (such as enzyme assay or genetic testing results for Gaucher disease) is not submitted, or if the completed form is not faxed to CVS Caremark at the required number.

Provide the most accurate diagnosis for the prescribed medication
Attach required supporting documentation when requested (e.g., enzyme assay or genetic testing results)
Fax the completed form to 1-866-237-5512

Definitions

Enzyme assay or genetic testing — confirmation of Gaucher disease

Required confirmation testEnzyme assay demonstrating deficiency of beta-glucocerebrosidase or genetic testing — attach results (ACTION REQUIRED)

Question on formForm asks: ‘Was the diagnosis of Gaucher disease confirmed by an enzyme assay demonstrating a deficiency of beta-glucocerebrosidase (glucosidase) enzyme activity or by genetic testing?’ — response required Yes/No

Documentation to includeAttach results of the enzyme assay or genetic testing with the prior authorization submission to CVS Caremark

Use for coverage determinationConfirmation by enzyme assay or genetic testing is required to support coverage for Gaucher disease indication

Potential consequenceFailure to attach the test results may result in denial of coverage or incomplete review

Background

Gaucher disease is an inherited lysosomal storage disorder caused by deficiency of the enzyme beta‑glucocerebrosidase; diagnosis is confirmed by an enzyme assay demonstrating deficiency of beta‑glucocerebrosidase or by genetic testing. Enzyme replacement therapy such as VPRIV is used for treatment of Gaucher disease and the prior authorization form requires documentation of the confirmed diagnosis and disease variant. The form specifically instructs to attach results of enzyme assay or genetic testing when confirmation is claimed, and it directs prescribers to indicate whether the request is for continuation of VPRIV and whether the patient is experiencing an inadequate response or intolerable adverse events on VPRIV.

OpenPayer

Prior Authorization Request — Specialty Medications (VPRIV / Gaucher disease)

Coverage Criteria

Coding

Provider Actions & Submission

Definitions

Continuation Therapy Criteria

Site of Care

Background