CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization request form — Prolia and listed biosimilars

Prior authorization form administered by CVS Caremark for HMSAMED Medicare Advantage members governing submission requirements for specified injectable bone-density agents (including Prolia and listed biosimilars); applies to providers submitting requests for coverage.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization request form — Prolia and listed biosimilars

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form to CVS Caremark at 1-866-237-5512 and attest supporting documentation is available.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-866-237-5512primary fax for submission

1-808-254-4414CVS Caremark contact

1-800-237-2767Specialty Customer Care

C26251-Aform identifier

Coverage Determination

Authorization decision tree

Coverage is determined by completing the following conditional criteria flow; approvals may be subject to dosing limits aligned with labeling and guidelines.

Initial authorization flow

Diagnosis or indication (Q1): Options include: Osteoporosis treatment; Osteoporosis prevention in an osteopenic postmenopausal woman; Increasing bone mass in a man with prostate cancer; Increasing bone mass in a woman with breast cancer; Glucocorticoid-induced osteoporosis; Other
Q1 lists indications and branches to subsequent questions as shown
Current therapy assessment (Q2–5): If patient currently receiving product, ask if receiving benefit; affirmative responses end questions; negative responses also recorded
Q2–5 handle continuation and benefit assessment
New therapy assessment (Q6–13):

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization request form — Prolia and listed biosimilars

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization form to CVS Caremark at 1-866-237-5512 and attest supporting documentation is available.

SourceLink

On This Page

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.

For new starts, Q6 identifies diagnosis and branches: osteoporosis treatment proceeds to sex/status question and high fracture risk assessment (Q7–8); prostate cancer and breast cancer indications require assessment of high fracture risk and cancer therapy status (Q9–12); glucocorticoid-induced osteoporosis assessed for high fracture risk (Q13)

Q6–13 guide eligibility for initiation

Diagnosis or indication (Q1): - Osteoporosis treatment (Continue to #4) - Osteoporosis prevention in an osteopenic postmenopausal woman (Continue to #4) - Increasing bone mass in a man with prostate cancer (Continue to #2) - Increasing bone mass in a woman with breast cancer (Continue to #2) - Glucocorticoid-induced osteoporosis (Continue to #2) - Other (No Further Questions)

From Q1 on form

The prior authorization form does not list any explicit coverage exclusions; instead, it presents an indication list where selecting Other directs the reviewer to No Further Questions. When Other is chosen the form provides no additional branching criteria or automatic denial language — the indication simply does not trigger further form questions and the reviewer must determine coverage from the information submitted.

The form does not enumerate specific conditions labeled as not medically necessary. Coverage determinations are driven by the responses to the criteria questions (indication, current use, benefit, high-fracture-risk and cancer-therapy status) and any supporting documentation attested to by the prescriber, rather than by a predefined list of non-covered diagnoses.

Requested Diagnosis & Coding Details

Requested diagnosis codingICD-10

ICD-10

Form requests the ICD-10 code relevant to the indication (blank on form)

inv-05: Patient weight — requested on form (kg)

Requested fieldPatient weight (recorded in kilograms on the form)

Unitskg (kilograms)

Location on formAdditional Demographic Information section — labeled 'Patient Weight' with blank line for entry

Related measurements requestedPatient height (separate fields for feet and inches) captured nearby

Submission, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain medications administered under this program. Providers must complete and fax the HMSAMED/CVS Caremark Prior Authorization form to 1-866-237-5512 and include all requested clinical information. Approvals may be subject to dosing limits per FDA labeling, accepted compendia, and evidence-based guidelines.

Fax: 1-866-237-5512
Phone (clinical questions): 1-808-254-4414
Specialty Customer Care (benefit/copay/delivery): CaremarkConnect 1-800-237-2767

Note

Clinical branching questions on the form

The prior authorization form contains branching clinical questions to document indication and current treatment status (e.g., osteoporosis treatment vs prevention, cancer‑related bone mass support, glucocorticoid‑induced osteoporosis), whether the patient is currently receiving the requested product, and whether the patient is deriving benefit from therapy. Answer all applicable items to support an appropriate review.

Indication selection (osteoporosis treatment, prevention, cancer-related, glucocorticoid-induced, other)
Current use and benefit questions (Yes/No branching to follow-up items)
High fracture risk and cancer‑therapy specific questions (ADT, aromatase inhibitor)

Documentation Required

Submission, attestation, and documentation requirements

The prescriber (or authorized signer) must attest on the form that the information provided is accurate and that supporting documentation is available for review if requested by CVS Caremark or the benefit plan sponsor. Incomplete, inaccurate, or missing diagnostic information and supporting documentation may result in denial of coverage.

Provider attestation signature and date required on the faxed form
Provide the most accurate diagnosis/indication to avoid processing delays or denial
Retain and make available supporting clinical documentation upon request

Denial Risk

Incomplete or inaccurate diagnosis may trigger denial

Failure to provide the most accurate diagnosis or required supporting documentation may lead to denial of the prior authorization request.

Incomplete or inaccurate diagnosis/indication may trigger denial
Ensure all branching questions are completed as applicable

Policy Purpose and Use

This prior authorization form is used to assess clinical indications for injectable bone-density–enhancing agents (e.g., Prolia and listed biosimilars). It captures the patient diagnosis (osteoporosis treatment or prevention, bone‑mass preservation in men with prostate cancer or women with breast cancer, glucocorticoid‑induced osteoporosis, or other), whether the patient is currently receiving the requested product and deriving benefit, and whether the patient is at high risk for fracture. Responses to these branching questions (Q1–Q13) guide the authorization pathway for initiation or continuation of therapy.

Key Definitions

inv-11: high risk for fracture — definition / flag used on the form

Definition / flag'High risk for fracture' is a checkbox question used to identify patients meeting a high-fracture‑risk pathway on the form (responses determine subsequent question flow)

Where usedAppears in branching questions: Q8 (postmenopausal/male pathway) and Q9 (prostate cancer pathway) to determine next steps

Consequence of a 'Yes' responseIf 'Yes' is selected, the form directs to 'No Further Questions' for Q8 or advances to additional cancer‑therapy questions per the flow at Q9–10

Consequence of a 'No' responseIf 'No' is selected, the form also directs to the next step or 'No Further Questions' as indicated by the question flow

Criteria for New Therapy Starts

Initial therapy pathway

For new therapy starts, complete Q6–Q13 on the form; the selected indication directs which subsequent questions must be answered to determine eligibility for initiation.

New start pathway: Q6 identifies indication; for osteoporosis treatment Q7–8 assess sex/status and high fracture risk; for osteoporosis prevention in an osteopenic postmenopausal woman no further questions are required; for prostate cancer Q9–10 assess fracture risk and ADT status; for breast cancer Q11–12 assess fracture risk and aromatase inhibitor therapy status; for glucocorticoid-induced osteoporosis Q13 assesses high fracture risk

Responses determine whether additional documentation or criteria are met for initiation

Q6 — Indication-specific branching: - Osteoporosis treatment -> Continue to #7 - Osteoporosis prevention in an osteopenic postmenopausal woman -> No Further Questions - Increasing bone mass in a man with prostate cancer -> Continue to #9 - Increasing bone mass in a woman with breast cancer -> Continue to #11 - Glucocorticoid-induced osteoporosis -> Continue to #13

From Q6 on form

Osteoporosis treatment branch (Q7–8): Q7: Is the patient male or postmenopausal? (Male / Postmenopausal patient / Neither) -> Continue to #8. Q8: Is the patient at high risk for fracture? (Yes -> No Further Questions; No -> No Further Questions)

From Q7–Q8 on form

Prostate cancer branch (Q9–10): Q9: Is the patient at high risk for fracture? (Yes -> Continue to #10; No -> Continue to #10). Q10: Is the patient currently receiving androgen deprivation therapy (ADT) for prostate cancer? (Yes -> No Further Questions; No -> No Further Questions)

From Q9–Q10 on form

Breast cancer branch (Q11–12): Q11: Is the patient at high risk for fracture? (Yes -> Continue to #12; No -> Continue to #12). Q12: Is the patient receiving adjuvant aromatase inhibition therapy for breast cancer? (Yes -> No Further Questions; No -> No Further Questions)

From Q11–Q12 on form

Glucocorticoid-induced osteoporosis branch (Q13): Q13: Is the patient at high risk for fracture? (Yes -> No Further Questions; No -> No Further Questions)

From Q13 on form

Criteria for Ongoing Therapy

Continuation/Benefit assessment

For patients currently receiving the requested product, the form requires assessment of current use and whether the patient is receiving benefit; affirmative responses conclude the prior authorization questions.

Current use: Q2 and Q4 ask if patient is currently receiving treatment with the requested product; if Yes, continue to Q3 or Q5 respectively to assess benefit

From Q2 and Q4 on form

Benefit assessment: Q3 and Q5 ask if the patient is receiving benefit from therapy. Answers: Yes -> No Further Questions; No -> No Further Questions

Affirmative or negative responses end the form flow for continuation requests

Step Therapy / Fail-First Requirements

Step	Requirement
1	No explicit step‑therapy (fail‑first) requirement is stated on the form; authorization follows an indication‑ and risk‑based question flow (Questions 1–13) to determine eligibility
2	The form uses branching clinical questions (diagnosis/indication, current use, benefit, sex/status, and high fracture risk or cancer‑therapy status) rather than requiring prior trial of an alternative agent
3	If 'Other' is selected for indication there are no further questions; selection of specific indications directs to the applicable continuation or initiation pathway as labeled on the form

Dispensing and Administration Site

Note

Indicate site of dispensing and administration

The form requests the site where the drug will be dispensed and where it will be administered, offering multiple options (home, office, infusion/ambulatory/outpatient hospital, pharmacy, and other); select the appropriate site(s) on the form.

Dispensing site options include Office, Outpatient Hospital, Pharmacy, Other, etc.
Administration site options include Ambulatory surgical, Home, Office, Outpatient Hospital, Pharmacy

Requested Products

Billing Rule

Select requested product (Prolia and listed alternatives)

The form lists Prolia and multiple named products (Bildyos, Conexxence, Enoby, Jubbonti, Ospomyv, Stoboclo) as selectable requested products; mark the product being requested on the form.