CurrentHawaii Medical Service Association (HMSA)Policy N/A
Remodulin_treprostinil_Prior_Authorization_Request
Prior authorization request form used by CVS Caremark (for HMSA members) to collect clinical and administrative information for coverage determination of Remodulin (treprostinil) for pulmonary hypertension. The form requests diagnosis, prescribing specialist, WHO classification, right heart catheterization data, and site of administration/dispensing details.
Policy Summary
PayerHawaii Medical Service Association (HMSA)
PolicyRemodulin_treprostinil_Prior_Authorization_Request
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionComplete and fax the Remodulin prior authorization form with required clinical documentation (RHC results, echocardiogram, diagnosis code, prescriber specialty) to CVS Caremark Specialty Programs at 1-866-237-5512.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes
1Drug covered via PA process
5WHO PH groups listed
3RHC data elements requested
Policy summary
CVS Caremark administers the prescription benefit for HMSA and requires prior authorization for certain medications, including Remodulin (treprostinil). Approvals may be subject to dosing limits consistent with FDA labeling, accepted compendia, and evidence-based practice guidelines.