HMSAMCD - Prior Authorization Request
A prior authorization request form and checklist administered by CVS Caremark for HMSA members to request coverage for RSV prophylaxis (e.g., Synagis) including demographic, clinical criteria questions, administration/dispensing site, dosing history, seasonality, and attestations required to make a coverage determination.
No material clinical or coverage changes.
Policy overview and intent
This is a CVS Caremark‑administered prior authorization request form for HMSA members to request coverage for RSV prophylaxis (e.g., Synagis/palivizumab). The form captures patient demographics, prescriber information, dispensing and administration site, ICD‑10 diagnosis code entry, sequential clinical questions for medical necessity, dosing history (number of doses received this RSV season), seasonality (HMSA RSV season: August 1 to February 29), and prescriber attestation/signature.
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