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.

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.

This prior authorization request form is used to collect clinical and administrative information to determine coverage for Remodulin (treprostinil). The form requests the diagnosis and ICD-10 code, the prescribing specialist (or consultation with a pulmonologist or cardiologist), WHO classification of pulmonary hypertension, right heart catheterization (RHC) data (pretreatment mean pulmonary arterial pressure in mmHg, pulmonary capillary wedge pressure in mmHg, and pulmonary vascular resistance in Wood units) when performed, Doppler echocardiogram reports when indicated, patient demographics, and site of dispensing/administration.

PayerHawaii Medical Service Association (HMSA)

PolicyRemodulin (treprostinil) prior authorization request form

Policy NumberN/A

StatusCURRENT

Last review2023-03

Effective date

Next review

Scope summaryPrior 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.

What the provider must do

Prior Authorization

Prior authorization submission

Complete and fax the Remodulin prior authorization form with required clinical documentation to CVS Caremark Specialty Programs at 1-866-237-5512.

Right heart catheterization (RHC) results
Echocardiogram (Doppler) reports
Diagnosis ICD-10 code
Prescriber specialty

Documentation Required

Attach diagnostic documentation

Attach right heart catheterization documentation (pretreatment mean pulmonary arterial pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance) if performed, and attach Doppler echocardiogram reports when indicated.

Billing Rule

Contact for authorization questions

For authorization questions contact CVS Caremark at 1-808-254-4414. For Specialty Customer Care inquiries contact CaremarkConnect or fax documents to 1-866-237-5512.

Where drug is dispensed (options)Office; Outpatient Hospital; Inpatient Hospital; Off Campus Outpatient Hospital; Urgent Care; Emergency Room; Birthing Center; Military Facility; Skilled Nursing Facility; Nursing Facility; Hospice; Inpatient Psychiatric; Psychiatric Residential Treatment; End Stage Renal Facility; Psychiatric Facility; Pharmacy

Where drug is administered (options)Ambulatory surgical; Inpatient hospital; Office; Outpatient Hospital; Pharmacy

Prescriber information requiredName; Specialty; NPI; Office telephone; Office fax; Prescriber signature and date

Patient demographics requiredPatient name; Patient ID; Date of birth; Weight (kg); Height (inches)

Prescribed by/consult with pulmonologist or cardiologist?Yes/No (form asks if prescribed by or in consultation with a pulmonologist or cardiologist)

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

SourceLink

On This Page

OpenPayer

Remodulin_treprostinil_Prior_Authorization_Request

Policy summary

Information required for prior authorization determination

What the provider must do

Requested diagnostic code

Numeric thresholds and defined terms

Document dates