2013 Prior Authorization Drug Requirements - CCHP

FORMULARY
DRUG
BRAND NAME
generic name
ABRAXANE
SUSP 1
acetylcysteine
soln. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
1
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ACTEMRA INJ 2
DRUG
TIER
LEVEL
COVERED
USES
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D.
Systemiconset
juvenile
idiopathic
arthritis (JIA).
Plus patients
already started
on tocilizumab
for a Covered
Use. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
For indication of
systemic-onset
JIA, may approve
for children and
adolescents 18
years of age or
younger. For
rheumatoid
arthritis (RA) and
Still's disease,
approve for adults.
PRESCRIBER
RESTRICTION
Adults with RA,
tocilizumab is to be
prescribed by a
rheumatologist or
in consultation
with a
rheumatologist.
Systemic-onset
JIA, tocilizumab is
to be prescribed by
a rheumatologist.
Castleman's
disease, approve if
patient is under the
care of an
oncologist or
hematologist.
COVERAGE
DURATION
Authorization
will be for 12
months.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
2
OTHER
CRITERIA
Adults with RA,
approve for
patients who
have tried for at
least 2 months
or who were
intolerant to one
of the following
TNF antagonists
, adalimumab,
certolizumab
pegol,
etanercept,
golimumab, or
infliximab.
Systemic-onset
JIA, approve for
patients who
have tried a
systemic

FORMULARY
DRUG
BRAND NAME
generic name
ADAGEN INJ. 2
adapalene cream 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
3
OTHER
CRITERIA
corticosteroid,
and either MTX
or sulfasalazine
or another
DMARD such
as etanercept.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not
otherwise N/A N/A N/A N/A
Authorization For topical
will be for 12 tretinoin
months, unless products
otherwise noted. (examples

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
excluded from
Part D.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
include Atralin,
Avita, Retin-A,
Retin-A Micro,
Tretin-X, and
generic topical
tretinoin),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
sebaceous
hyperplasia/cyst,
basal cell
carcinoma [skin
cancer],
confluent and
reticulated
papillomatosis)
can be made if
the patient has
tried at least 1
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
4

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
other therapy.
For topical
adapalene
products
(examples
include Differin
gel, Differin
cream, etc. and
generic
adapalene
products),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
sebaceous
hyperplasia/cyst,
basal cell
carcinoma [skin
cancer],
confluent and
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
5

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
reticulated
papillomatosis,
Darier's disease,
molluscum
contagiosum)
can be made if
the patient has
tried at least 1
other therapy.
Coverage of the
combination
clindamycin
plus tretinoin
product (Ziana)
and the
combination
adapalene plus
benzoyl
peroxide
product
(Epiduo) is
recommended
for acne vulgaris
ONLY and all
other indications
are not
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
6

FORMULARY
DRUG
BRAND NAME
generic name
adapalene gel 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
7
OTHER
CRITERIA
recommended.
For topical
tretinoin
products
(examples
include Atralin,
Avita, Retin-A,
Retin-A Micro,
Tretin-X, and
generic topical
tretinoin),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
sebaceous
hyperplasia/cyst,
Authorization basal cell
will be for 12 carcinoma [skin
months, unless cancer],
otherwise noted. confluent and

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
reticulated
papillomatosis)
can be made if
the patient has
tried at least 1
other therapy.
For topical
adapalene
products
(examples
include Differin
gel, Differin
cream, etc. and
generic
adapalene
products),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
sebaceous
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
8

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
hyperplasia/cyst,
basal cell
carcinoma [skin
cancer],
confluent and
reticulated
papillomatosis,
Darier's disease,
molluscum
contagiosum)
can be made if
the patient has
tried at least 1
other therapy.
Coverage of the
combination
clindamycin
plus tretinoin
product (Ziana)
and the
combination
adapalene plus
benzoyl
peroxide
product
(Epiduo) is
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
9

FORMULARY
DRUG
BRAND NAME
generic name
ADCIRCA TAB 2
adriamycin inj. 1
DRUG
TIER
LEVEL
COVERED
USES
All FDAapproved
indications not
otherwise
excluded from
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For initial approval for
use in pulmonary arterial
hypertension (PAH),
approve if patient has
had a right-heart
catheterization to
confirm diagnosis of
PAH to ensure
appropriate medical
assessment. For patients
currently receiving
sildenafil or tadalafil,
approve if patient has a
diagnosis of PAH.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
For PAH, if Authorization
prescribed by, or in will be for 12
consultation with, a months, unless
cardiologist or a otherwise
pulmonologist. specified.
Part D. N/A
N/A
N/A
This drug may
be covered
under
Medicare Part
B or D
depending N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
10
OTHER
CRITERIA
recommended
for acne vulgaris
ONLY and all
other indications
are not
recommended.

FORMULARY
DRUG
BRAND NAME
generic name
ADVAIR
DISKUS 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D. Plus
COPD.
Chronic
bronchitis.
Emphysema.
Postinfectious
cough (ie,
cough
persisting after
an acute
respiratory N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
11
OTHER
CRITERIA
N/A

FORMULARY
DRUG
BRAND NAME
generic name
ADVAIR HFA
INHALER 2
AFINITOR TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
infection has
resolved).
All FDAapproved
indications not
otherwise
excluded from
Part D. Plus
COPD.
Chronic
bronchitis.
Emphysema.
Postinfectious
cough (ie,
cough
persisting after
an acute
respiratory
infection has
resolved). N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
For the treatment of
progressive
neuroendocrine tumors
of pancreatic origin in
patients with
unresectable, locally N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
Approved for
duration of
contract year
subject to
formulary
change and
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
12
OTHER
CRITERIA
N/A
N/A

FORMULARY
DRUG
BRAND NAME
generic name
albuterol neb 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
advanced, or metastatic
member
disease. For the
eligibility.
treatment of patients
with advanced renal cell
carcinoma after failure
of treatment with Sutent
or Nexavar. For the
treatment of patients
with subependymal giant
cell astrocytoma
associated with tuberous
sclerosis who require
therapeutic intervention
but are not candidates
for curative surgical
resection.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
13
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
amifostine inj. 1
aminosyn inj. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
14
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
AMINOSYN II
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
15
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
AMINOSYN M
INJ. 2
AMINOSYN-
HBC INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
16
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
AMINOSYN-PF
INJ. 2
AMPYRA TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
N/A N/A N/A
MS. If prescribed
by, or in
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
17
OTHER
CRITERIA
Initial approval For initial
for MS, 90 days. approval for

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
indications not
otherwise
excluded from
Part D. Plus
patient already
started on
dalfampridine
extendedrelease
for
Multiple
Sclerosis
(MS).
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
consultation with,
an MS specialist.
COVERAGE
DURATION
OTHER
CRITERIA
Subsequent MS, authorize
authorization for for 90 days.
12 mos if patient After up to 90
had a response. days of
dalfampridine
extended-release
therapy, if MS
patient has had a
response to
therapy as
determined by
prescribing
physician (eg,
increased
walking
distance,
improved
leg/limb
strength,
improvement in
activities of
daily living),
then an
additional
authorization is
allowed.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
18

FORMULARY
DRUG
BRAND NAME
generic name
ANDROGEL 2
ARALAST NP
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. Alpha-
1 antitrypsin
(AAT)
deficiencyassociated
panniculitis. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Two morning
testosterone levels fall
below the normal range
for a healthy adult male. N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
19
N/A
For AAT deficiency
with emphysema (or
COPD), approve in
patients with baseline
(pretreatment) alpha1-
antitrypsin serum
concentration less than
11 microM (11
micromol/L) or 80
mg/dL. N/A N/A
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
Authorization
will be for 12
months, unless
otherwise
specified.
OTHER
CRITERIA
N/A
For all covered
uses, the patient
is required to try
Aralast NP first
line. For AAT
deficiency with
emphysema (or
COPD), approve
in patients with
baseline
(pretreatment)
alpha1-
antitrypsin
serum
concentration
less than 11
microM (11
micromol/L) or

FORMULARY
DRUG
BRAND NAME
generic name
ARCALYST
INJ. 2
ARRANON INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. Plus
patient already
started on
rilonacept for
Muckle Wells
Syndrome
(MWS) or
Familial Cold
Autoinflamma
tory Syndrome
(FCAS). N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Greater than or
equal to 12 years
of age.
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
20
OTHER
CRITERIA
80 mg/dL.
Patients already
started on
rilonacept for
MWS/FCAS
may receive
authorization if
Initial approval they have had a
of MWS/FCAS, response and are
2 mos. continuing
Subsequent therapy to
authorization for maintain
12 mos if patient response/remissi
had a response. on.
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
ARZERRA 2
ATGAM INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
21
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
AVONEX KIT 2
DRUG
TIER
LEVEL
COVERED
USES
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
All FDAapproved
indications not
otherwise
excluded from
Part D.
Multiple
Sclerosis N/A N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Prescribed by or
after consultation
with a neurologist
or an MS
specialist.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
22
OTHER
CRITERIA
Approve for
patients already
started on
Avonex. For
patients not
currently on
Avonex,
approve if the
patient has
previously tried
Betaseron,
Copaxone, or
Rebif.

FORMULARY
DRUG
BRAND NAME
generic name
AVONEX
PREFILL KIT 2
AXIRON SOLN 2
azathioprine inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
All FDAapproved
indications not
otherwise
excluded from
Part D.
Multiple
Sclerosis N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
AGE
RESTRICTION
Two morning
testosterone levels fall
below the normal range
for a healthy adult male.
Patient must have tried
and failed
ANDRODERM and
ANDROGEL N/A N/A
PRESCRIBER
RESTRICTION
Prescribed by or
after consultation
with a neurologist
or an MS
specialist.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
N/A
This drug may
be covered
under
Medicare Part
B or D N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
23
OTHER
CRITERIA
Approve for
patients already
started on
Avonex. For
patients not
currently on
Avonex,
approve if the
patient has
previously tried
Betaseron,
Copaxone, or
Rebif.

FORMULARY
DRUG
BRAND NAME
generic name
azathioprine tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
24
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
BETASERON
INJ. 2
BICNU INJ. 2
bleomycin sulfate
inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
determination.
All FDAapproved
Prescribed by or Authorization
indications not
after consultation will be for 12
otherwise
with a neurologist months, unless
excluded from
or an MS otherwise
Part D. N/A N/A N/A
specialist. specified. N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
25
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
BOSULIF
TAB 2
BOTOX INJ 2
DRUG
TIER
LEVEL
COVERED
USES
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
All FDAapproved
management of
Use in the
indications not cosmetic uses
otherwise (eg, facial
excluded from rhytides, frown N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
Authorization
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
26
N/A
Tinnitus if
prescribed by ENT. will be for 12
Headache if months, unless
prescribed by, or otherwise
after consultation specified.
OTHER
CRITERIA
N/A
Primary axillary
hyperhydrosis
after trial with at
least 1 topical
agent (eg,

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
Part D. Plus
Achalasia.
Anal Fissure.
BPH. Chronic
facial
pain/pain
associated
with TMJ
dysfunction.
Chronic low
back pain.
Headache
(migraine,
chronic
tension HA,
whiplash,
chronic daily
HA).
Palmar/plantar
and facial
hyperhidrosis.
Myofascial
pain. Salivary
hypersecretion
. Spasticity
(eg, due to
EXCLUSION
CRITERIA
lines, glabellar
wrinkling,
horizontal neck
rhytides, mid
and lower face
and neck
rejuvenation,
platsymal bands,
rejuvenation of
the peri-orbital
region), allergic
rhinitis, gait
freezing in
Parkinsons
disease,
vaginismus,
interstitial
cystitis, or
Crocodile tears
syndrome.
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
with, a neurologist
or HA specialist.
COVERAGE
DURATION
OTHER
CRITERIA
aluminum
chloride). BPH
after trial with at
least 2 other
therapies (eg,
alpha1-blocker,
5 alphareductase
inhibitor,
TURP,
transurethral
microwave heat
treatment,
TUNA,
interstitial laser
therapy, stents,
various forms of
surgery).
Chronic low
back pain after
trial with at least
2 other
pharmacologic
therapies (eg,
NSAID,
antispasmodics,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
27

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
cerebral palsy,
stroke, brain
injury, spinal
cord injury,
MS,
hemifacial
spasm).
Essential
tremor.
Dystonia other
than cervical
(eg, focal
dystonias,
tardive
dystonia,
anismus).
Bladder/voidin
g/urethral
dysfunction.
Frey's
syndrome
(gustatory
sweating).
Ophthalmic
disorders (eg,
esotropia,
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
muscle
relaxants,
opioids,
antidepressants)
and if being
used as part of a
multimodal
therapeutic pain
management
program.
Tinnitus after a
trial with at least
2 other
pharmacologic
therapies (eg,
lidocaine,
antihistamines,
antidepressants,
anxiolytics,
diuretics,
anticonvulsants,
antispastics) and
tinnitus
retraining
therapy.
Headache (eg,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
28

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
exotropia,
nystagmus,
facial nerve
paresis).
Speech/voice
disorders (eg,
dysphonias).
Tourette's
syndrome.
Additional
indications
will be
evaluated by a
pharmacist
and/or a
physician on a
case-by-case
basis.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
migraine,
chronic tension
headache,
whiplash,
chronic daily
headache) after
a trial with at
least 2 other
pharmacologic
therapies (eg,
anticonvulsants,
antidepressants,
beta-blockers,
calcium channel
blockers, nonsteroidal
antiinflammatory
drugs).
Palmar/plantar
and facial
hyperhidrosis
after a trial with
at least 1 topical
agent (eg,
aluminum
chloride).
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
29

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
Essential tremor
after a trial with
at least 1 other
pharmacologic
therapy (eg,
primidone,
propranolol,
benzodiazepines
, gabapentin,
topiramate).
Bladder/Voiding
/Urethral
dysfunction
after a trial with
at least 1 other
pharmacologic
therapy (eg, oral
antimuscarinic
agents).
Gastroparesis
after a trial with
at least 1
promotility drug
(eg,
metoclopramide,
tegasterod,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
30

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
All FDAapproved
indications not
otherwise
excluded from
Part D. All
medically
accepted
indications not
Approved for
duration of
contract year
subject to
Restricted to or in formulary
BRILINTA
otherwise
excluded from
consult with
Cardiology
change and
member
TAB 2 Part D N/A N/A N/A
Specialist. eligibility. N/A
budesonide susp. 1 This drug may N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
31
OTHER
CRITERIA
erythromycin).
Tourette's
syndrome if
after a trial with
at least 1 more
commonly used
pharmacologic
therapy (eg,
neuroleptics,
clonidine,
SSRIs,
psychostimulant
s).

FORMULARY
DRUG
BRAND NAME
generic name
BUSULFEX
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
32
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
BYETTA INJ. 2
calcitriol cap 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
33
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
calcitriol inj. 1
calcitriol soln. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
34
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
CAPRELSA
TAB 2
carboplatin inj. 1
DRUG
TIER
LEVEL
COVERED
USES
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Prescribed by an
Oncologist or
Endocrinologist or
under the direct
consultation of an
Oncologist or
Endocrinologist.
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
35
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
CARIMUNE NF
INJ. 2
carisoprodol/
aspirin tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from N/A
N/A
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria N/A
Authorization
will be for 1
month.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
36
OTHER
CRITERIA
Musculoskeletal
conditions/disor
ders, approve if
the patient has
tried two other

FORMULARY
DRUG
BRAND NAME
generic name
CAYSTON 28
DAY 2
CELLCEPT IV
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
37
OTHER
CRITERIA
Part D. apply. therapies for the
current
condition.
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
Restricted to or in
consult with
Infectious Disease
or Pulmonology
Specialist.
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
Approval will
be based off
BvD coverage
determination.

FORMULARY
DRUG
BRAND NAME
generic name
CELLCEPT
SUSP. 2
CEREZYME
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
38
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
CERUBIDINE
INJ 2
CESAMET
CAP 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
39
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
chlorzoxazone
tab 1
chorionic
gonadotropin inj. 1
DRUG
TIER
LEVEL
COVERED
USES
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
All FDAapproved
indications not
otherwise
excluded from N/A
N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
Prepubertal
cryptorchidism,
child or adolescent.
Hypospadias or
epispadias. N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 1
month.
Authorization
will be for 12
months, unless
noted otherwise.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
40
OTHER
CRITERIA
Musculoskeletal
conditions/disor
ders, approve if
the patient has
tried two other
therapies for the
current
condition.
Hypogonadotro
pic
hypogonadism
in males.
Preoperative use

FORMULARY
DRUG
BRAND NAME
generic name
ciclopirox nail
lacquer 1
DRUG
TIER
LEVEL
COVERED
USES
Part D.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Allowed use only
in patients 4 years
and older.
Onychomycosis must be
confirmed by positive
KOH, fungal culture,
DTM culture, nail
biopsy, or histologic
examination (PAS) is
required before therapy
initiation. Before a
second course of
treatment is permitted
for onychomycosis, a
culture must demonstrate
a fungal infection. Use
of topical ciclopirox 8%
solution with terbinafine,
itraconazole, or
fluconazole (for
onychomycosis use) is
not permitted. N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for up to
48 weeks. N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
41
OTHER
CRITERIA
for hypospadias
and chordee OR
total epispadias
and bladder
exstrophy in
male infants or
toddlers.

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For moderate to severe
RA requires intolerance
to or failure of therapy
with methotrexate
(greater than 20mg/wk). N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
For RA must be
prescribed by
Rheumatology
Specialist. For
Crohn's Disease
must be prescribed
by
Gastroenterology
Specialist.
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
CIMZIA INJ 2
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
cisplatin inj 1 determination. N/A N/A N/A N/A N/A N/A
CLINIMIX E 2 This drug may N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
42
OTHER
CRITERIA
For members
with a diagnosis
of early, severeonset
RA, or
Crohn's Disease
additional
required medical
information is
not required.

FORMULARY
DRUG
BRAND NAME
generic name
INJ.
CLINIMIX INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
43
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
clinisol sf inj. 2
colistimethate
inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
44
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
COMETRIQ
PACK 2
COPAXONE
KIT 2
DRUG
TIER
LEVEL
COVERED
USES
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D.
Multiple N/A
Patients with a diagnosis
of multiple sclerosis
(MS) or have
experienced an attack
and who are at risk of
MS
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
45
N/A
Prescribed by or
after consultation
with a neurologist
or an MS
specialist.
Authorization
will be for 12
months, unless
otherwise
specified.
OTHER
CRITERIA
N/A
N/A

FORMULARY
DRUG
BRAND NAME
generic name
cromolyn neb 1
CUBICIN INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Sclerosis
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
46
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
cyclophosphamid
e tab 1
cyclosporine cap 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
47
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
cyclosporine inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
48
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
cyclosporine
modified cap 1
cyclosporine
modified soln. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
49
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
cyproheptadine
syrup 1
DRUG
TIER
LEVEL
COVERED
USES
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
50
OTHER
CRITERIA
Approve if the
patient has tried
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,
desloratadine,
levocetirizine,
fexofenadine/ps
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
condition.
Approve
promethazine
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral
anti-emetic
agent
(ondansetron,
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
diphenhydramin
e (capsules or
elixir) if the
patient has tried
at least two
other FDAapproved
products for the
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
51

FORMULARY
DRUG
BRAND NAME
generic name
cyproheptadine
tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
52
OTHER
CRITERIA
management of
insomnia.
Approve
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
pamoate
(capsules) if the
patient has tried
at least two
other FDAapproved
products for the
management of
anxiety.
Approve if the
patient has tried
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
desloratadine,
levocetirizine,
fexofenadine/ps
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current
condition.
Approve
promethazine
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral
anti-emetic
agent
(ondansetron,
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
53

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
54
OTHER
CRITERIA
diphenhydramin
e (capsules or
elixir) if the
patient has tried
at least two
other FDAapproved
products for the
management of
insomnia.
Approve
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
pamoate
(capsules) if the
patient has tried
at least two
other FDAapproved
products for the
management of
anxiety.
cytarabine inj. 1 This drug may N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
dacarbazine inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
55
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
DACOGEN
INJ. 2
daunorubicin inj 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
56
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
dexrazoxane inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
57
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
diphenhydramine
cap 1
DRUG
TIER
LEVEL
COVERED
USES
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
58
OTHER
CRITERIA
Approve if the
patient has tried
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,
desloratadine,
levocetirizine,
fexofenadine/ps
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current
condition.
Approve
promethazine
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
anti-emetic
agent
(ondansetron,
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
diphenhydramin
e (capsules or
elixir) if the
patient has tried
at least two
other FDAapproved
products for the
management of
insomnia.
Approve
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
59

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
60
OTHER
CRITERIA
pamoate
(capsules) if the
patient has tried
at least two
other FDAapproved
products for the
management of
anxiety.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
DOCETAXEL
INJ. 2
DOXIL INJ. 2 This drug may N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
doxorubicin inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
61
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
dronabinol cap 1
ELITEK INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
62
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ELOXATIN
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
63
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ELSPAR INJ. 2
EMEND CAP 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
64
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
EMEND PACK 2
ENBREL INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not N/A
For moderate to severe
RA, Psoriatic Arthritis or
Reactive Arithritis N/A
Rheumatoid
Arthritis, Psoriatic
Arthritis, Reactive
Approved for
duration of the
contract year
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
65
OTHER
CRITERIA
For members
with a diagnosis
of early, severe-

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
otherwise
excluded from
Part D.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
requires intolerance to or
failure of therapy with
methotrexate (greater
than 20mg/wk). Plaque
Psoriasis: Failure of
methotrexate at a dose of
15mg/week or failed
soriatane.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Arthritis and
Ankylosing
Spondylitis:
Prescriber must be
a Rheumatologist.
All Plaque
Psoriasis:
Prescriber must be
a Dermatologist.
COVERAGE
DURATION
subject to
formulary
change and
member
eligibility.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
ENGERIX-B
make the
INJ. 2 determination. N/A N/A N/A N/A N/A N/A
enoxaparin inj. 1 This drug may N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
66
OTHER
CRITERIA
onset RA,
additional
required medical
information is
not required.

FORMULARY
DRUG
BRAND NAME
generic name
EPOGEN INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D worded
as anemia
associated
with chronic
renal failure
(CRF), N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
CRF
anemia.Hemoglobin
(Hb) of less than or
equal to 10.0 g/dL to
start.Hb less than or
equal to 12.0 g/dL if
previously on epoetin
alfa (EA) or
Aranesp.Anemia
w/myelosuppressive
chemotx.Hb
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
67
N/A
AA, prescribed by
a hematologist.
Preop approval:
1 month. All
others initial
appr 3months.
Reauth at 3
month intervals
OTHER
CRITERIA
Part B versus
Part D
determination
will be made at
time of prior
authorization
review per CMS
guidance to
establish if the
drug prescribed
is to be used for

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
including
patients on
dialysis and
not on
dialysis, and
worded as
anemia
secondary to
myelosuppress
ive anticancer
chemotherapy
in solid
tumors,
multiple
myeloma,
lymphoma,
and
lymphocytic
leukemia. Plus
anemia in
patients with
HIV who are
receiving
zidovudine.
Anemic
patients (Hb of
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
immediately prior to EA
is 10.0 g/dL or less (or
hematocrit [Hct] is 30%
or less).EA maintenance
is starting dose if Hb
level remains 10.0 g/dL
or less (or Hct remains
30% or less) 4 wks after
start and Hb rise is 1.0
g/dL or more (Hct rise is
3% or more).Pts w/Hb
rises less than 1.0 g/dL
(Hct rise less than 3%)
vs pretx baseline over 4
wks of tx and Hb is less
than 10.0 g/dL after 4
wks of tx (Hct is less
than 30%), the
recommended FDA
starting dose may be
increased once by
25%.Continued use is
not reasonable/necessary
if Hb rises less than 1.0
g/dL (Hct rise less than
3%) vs pretx baseline by
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
an end-stage
renal disease
(ESRD)-related
condition.
Anemia
secondary to
myelosuppressiv
e anticancer
chemotherapy in
solid tumors,
multiple
myeloma,
lymphoma, and
lymphocytic
leukemia. Pts
with Hb rise of
less than 1.0
g/dL (or Hct 3%
or less) and Hb
levels is less
than 10.0 g/dL
after 4 wks
therapy, the
recommended
FDA dose may
be increased
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
68

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
13.0 g/dL or
less) at high
risk for
perioperative
transfusions
(secondary to
significant,
anticipated
blood loss and
are scheduled
to undergo
elective,
noncardiac,
nonvascular
surgery to
reduce the
need for
allogeneic
blood
transfusions).
Anemia due to
myelodysplast
ic syndrome
(MDS).
Anemia
associated
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
8 wks of tx.Continued
EA is not
reasonable/necessary if
there is a rapid Hb rise
more than 1.0 g/dL (Hct
more than 3%) over 2
wks of tx unless Hb
remains below or
subsequently falls to less
than 10.0 g/dL (or Hct is
less than
30%).Continuation/reins
titution of EA must have
dose reduction of 25% of
previous dose. MDS,
approve if Hb is 12.0
g/dL or less.Previously
receiving Aranesp or
EA, approve if Hb is
12.0 g/dL or less. An
additional 6 months
allowed after first 6
months if Hb is 12.0
g/dL or less. Anemia in
HIV (with or without
zidovudine), Hb is 10.0
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
once by 25%.
Continued
epoetin alfa use
is not reasonable
or necessary if
the Hb rise is
less than 1.0
g/dL (or Hct is
less than 3%)
compared to
pretreatment
baseline by 8
weeks of
treatment.
Continued
epoetin alfa
administation is
not reasonable
and necessary if
there is a rapid
rise in Hb or
more than 1.0
g/dL (or Hct
more than 3%)
over 2 weeks of
treatment unless
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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69

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
with use of
ribavirin
therapy for
hepatitis C (in
combination
with interferon
or pegylated
interferon alfa
2a/2b
products).
Anemia in
HIV-infected
patients.
Anemia in
heart failure
(HF).
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
g/dL or less or
endogenous
erythropoetin levels are
500 munits/mL or less at
tx start.Previously on EA
approve if Hb is 12.0
g/dL or less.Anemia due
to ribavirin for Hep C,
Hb is 10.0 g/dL or less at
tx start. All conds, deny
if Hb exceeds 12.0 g/dL.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
the Hb remains
below or
subsequently
falls to less than
10.0 g/dL (or
Hct less than
30%).
Continuation
and reinstitution
of epoetin alfa
must include a
dose reduction
of 25% from the
previously
administered
dose.
Continuation
and reinstitution
of Aranesp must
include a dose
reduction of
25% from the
previously
administered
dose. Anemia in
HF, approve
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
70

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
initial trial of up
to 2 months for
patients with
more severe HF,
Hb of 10.0 g/dL
or less, anemia
persists despite
transfusions or
pt has
contraindication
s to transfusions.
Deny if Hb is
more than 12.0
g/dL. Further
approval after
initial course
will be
determined on a
case-by-case
basis after
evaluation by a
pharmacist
and/or
physician.
Anemia of
chronic disease,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
71

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
approve initial
trial of 3 months
for patients with
symptomatic
anemia of 10.0
g/dL or less,
anemia persists
despite
transfusions or
cannot tolerate
or undergo
transfusions,
and/or low
erythropoietin
levels ot failure
of other
treatment
modalities (eg,
iron
supplementation
). Other causes
of anemia have
been ruled out.
Deny if Hb is
more than 12.0
g/dL. Further
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
72

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
approval after
initial course
will be
determined on a
case-by-case
basis after
evaluation by a
pharmacist
and/or
physician.
Treatment of
AA, approve
initial trial of up
to 1 month for
patients with
symptomatic
anemia of less
than 11.0 g/dL.
Deny if Hb is
more than 12.0
g/dL. Further
approval after
initial course
will be
determined on a
case-by-case
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
73

FORMULARY
DRUG
BRAND NAME
generic name
ERBITUX
SOLN 2
ERIVEDGE
CAP 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
74
OTHER
CRITERIA
basis after
evaluation by a
pharmacist
and/or
physician.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from N/A N/A N/A
Restricted to or in
consult with
Oncology
Specialist.
Approved for
duration of
contract year
subject to
formulary
N/A

FORMULARY
DRUG
BRAND NAME
generic name
estazolam tab 1
etoposide inj. 1
DRUG
TIER
LEVEL
COVERED
USES
Part D. All
medically
accepted
indications not
otherwise
excluded from
Part D
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDA
approved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Prior Authorization
required for
members 65 and
older
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
change and
member
eligibility.
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
75
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
EXTAVIA INJ. 2
fentanyl lollipop 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Prescribed by or
after consultation
with a neurologist
or an MS
specialist.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
For breakthrough Authorization
chronic pain, will be for 12
prescriber is a pain months, unless
management otherwise
specialist. specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
76
OTHER
CRITERIA
N/A
For
breakthrough
pain in patients
with cancer and
for breakthrough
chronic (noncancer)
pain, if
patient is unable
to swallow, has
dysphagia,
esophagitis,
mucositis, or
uncontrollable
nausea/vomiting
OR patient is

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
unable to take 2
other shortacting
narcotics
(eg, oxycodone,
morphine
sulfate,
hydromorphone,
etc) secondary
to allergy or
severe adverse
events AND
patient is on or
will be on a
long-acting
narcotic (eg,
Duragesic), or
the patient is on
intravenous,
subcutaneous, or
spinal
(intrathecal,
epidural)
narcotics (eg,
morphine
sulfate,
hydromorphone,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
77

FORMULARY
DRUG
BRAND NAME
generic name
FIRMAGON
INJ 2
fludarabine inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
78
OTHER
CRITERIA
fentanyl citrate).
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
fluorouracil inj. 1
FOLOTYN INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
79
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
FORTEO SOLN. 2
DRUG
TIER
LEVEL
COVERED
USES
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
For
hypoparathyroidis Authorization
m, the patient must will be for 12
be under the care months, unless
of an
otherwise
endocrinologist. specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
80
OTHER
CRITERIA
Forteo may be
approved for the
covered
osteoporosis
indications if the
patient has tried
an oral or
intravenous
bisphosphonate
(eg, alendronate,
risedronate,
ibandronate,
zoledronic acid

FORMULARY
DRUG
BRAND NAME
generic name
FREAMINE III
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
81
OTHER
CRITERIA
[Reclast]), or if
the patient has
severe renal
impairment (eg,
creatinine
clearance less
than 30
mL/min) or
chronic kidney
disease, or if the
patient has
multiple
vertebral
fractures.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
gemcitabine inj. 1
gengraf cap 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
82
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
gengraf soln. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
83
OTHER
CRITERIA

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
GILENYA
CAP 2
DRUG
TIER
LEVEL
COVERED
USES
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For use in Multiple
Sclerosis (MS), patient
has a relapsing form of
MS.
AGE
RESTRICTION
N/A
PRESCRIBER
RESTRICTION
Prescribed by a
neurologist or an
MS specialist.
COVERAGE
DURATION
Authorization
will be for 12
months.
OTHER
CRITERIA
For use in MS,
patient has a
relapsing form
of MS and
patient has tried
interferon beta-
1a intramuscular
(Avonex),
interferon beta-
1a subcutaneous
(Rebif),
interferon beta-
1b (Betaseron or
Extavia), or
glatiramer
acetate
(Copaxone).
Exceptions to
having tried an
interferon beta-
1a or -1b
product
(Avonex,
Betaseron,
Extavia, or
Rebif) or
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
84

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
85
OTHER
CRITERIA
glatiramer
acetate
(Copaxone) can
be made if the
patient is unable
to administer
injections due to
dexterity issues
or visual
impairment.
Patients who
have tried
natalizumab
(Tysabri) for
MS and have a
relapsing form
of MS will
receive
authorization,
they are not
required to try
an interferon
beta product or
glatiramer
acetate.
GLEEVEC TAB 2 All medically- N/A Diagnosis for which N/A N/A Authorization For CML, new

FORMULARY
DRUG
BRAND NAME
generic name
granisetron inj. 1
DRUG
TIER
LEVEL
COVERED
USES
accepted
indications not
otherwise
excluded from
Part D.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Gleevec is being used.
For indications of CML
and ALL, the
Philadelphia
chromosome (Ph) status
of the leukemia must be
reported. New patients
with CML and ALL
which is Ph-positive
may receive
authorization for
Gleevec.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
will be for 12
months.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
86
OTHER
CRITERIA
patient must
have Ph-positive
CML for
approval of
Gleevec. For
ALL, new
patient must
have Ph-positive
ALL for
approval of
Gleevec.

FORMULARY
DRUG
BRAND NAME
generic name
granisetron tab 1
GRANISOL
SOLN. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
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OTHER
CRITERIA

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
HALAVEN
make the
INJ. 2 determination. N/A N/A N/A N/A N/A N/A
heparin inj. 1 This drug may N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
88

FORMULARY
DRUG
BRAND NAME
generic name
heparin sodium /
d5w inj 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
89
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
heparin/nacl inj. 1
HEPATASOL
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
90
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
HERCEPTIN
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
91
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
HIZENTRA
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
The type of primary
humoral
immunodeficiency or
primary
immunodeficiency
(PID).
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
92
N/A
Primary
immunodeficiency
(PID) or primary
humoral
immunodeficiency,
if prescribed by a
or in consultation
with an
allergist/immunolo
gist, immunologist,
otolaryngologist
(ear nose and
throat [ENT]
physician), or an
infectious disease
physician who
treats patients with
PID/primary
humoral
immunodeficiency.
Authorization
will be for 12
months, unless
otherwise
specified.
OTHER
CRITERIA
Approve for
patients with
PID or primary
humoral
immunodeficien
cy if they have
previously
received
immune
globulin given
intravenously
(IV) (eg,
Carimune,
Privigen, etc.) or
immune
globulin given
subcutaneously
(SC). Approve
for patients with
PID who have
been previously
treated with
immune
globulin therapy
given

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
subcutaneously
(SC) or who are
continuing
subcutaneous
immune
globulin therapy
previously
started.
Exceptions may
be given for
patients with
PID/primary
humoral
immunodeficien
cy without prior
IV or SC
immune
globulin use.
HUMIRA KIT 2
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
For the treatment of RA
member must have tried
and failed Enbrel and
Cimzia. For the
treatment of Plaque
Psoriasis, Psoriatic
Arthritis or ankylosing
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
93
N/A
Rheumatoid
Arthritis, Psoriatic
Arthritis, Reactive
Arthritis and
Ankylosing
Spondylitis=
prescriber must be
Approved for
duration of
contract year
subject to
formulary
change and
member
N/A

FORMULARY
DRUG
BRAND NAME
generic name
hydroxyzine
pamoate cap 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
spondylitis must have
tried and failed Enbrel.
For the treatment of
Crohn's Disease must
have tried and failed
Cimzia
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
a Rheumatologist. eligibility.
Crohn's Disease=
prescriber must be
a
Gastroenterologist.
Plaque Psoriasis=
prescriber must be
a Dermatologist.
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
94
OTHER
CRITERIA
Approve if the
patient has tried
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,
desloratadine,
levocetirizine,
fexofenadine/ps
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current
condition.

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
Approve
promethazine
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral
anti-emetic
agent
(ondansetron,
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
diphenhydramin
e (capsules or
elixir) if the
patient has tried
at least two
other FDAapproved
products for the
management of
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
95

FORMULARY
DRUG
BRAND NAME
generic name
hydroxyzine
syrup 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
96
OTHER
CRITERIA
insomnia.
Approve
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
pamoate
(capsules) if the
patient has tried
at least two
other FDAapproved
products for the
management of
anxiety.
Approve if the
patient has tried
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,
desloratadine,

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
levocetirizine,
fexofenadine/ps
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current
condition.
Approve
promethazine
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral
anti-emetic
agent
(ondansetron,
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
diphenhydramin
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
97

FORMULARY
DRUG
BRAND NAME
generic name
hydroxyzine tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
98
N/A
Authorization
will be for 12
OTHER
CRITERIA
e (capsules or
elixir) if the
patient has tried
at least two
other FDAapproved
products for the
management of
insomnia.
Approve
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
pamoate
(capsules) if the
patient has tried
at least two
other FDAapproved
products for the
management of
anxiety.
Approve if the
patient has tried

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
indications not
otherwise
excluded from
Part D.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
approve. Patients
aged 65 years and
older, other criteria
apply.
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
months, unless
otherwise
specified.
OTHER
CRITERIA
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,
desloratadine,
levocetirizine,
fexofenadine/ps
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current
condition.
Approve
promethazine
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral
anti-emetic
agent
(ondansetron,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
99

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
diphenhydramin
e (capsules or
elixir) if the
patient has tried
at least two
other FDAapproved
products for the
management of
insomnia.
Approve
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
pamoate
(capsules) if the
patient has tried
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
100

FORMULARY
DRUG
BRAND NAME
generic name
idarubicin inj 1
ifosfamide inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
101
OTHER
CRITERIA
at least two
other FDAapproved
products for the
management of
anxiety.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
INLYTA TAB 2
intralipid inj. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D. All
medically
accepted
indications not
otherwise
excluded from
Part D N/A N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Restricted to or in
consult with
Oncology
Specialist.
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
N/A
This drug may
be covered N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
102
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ipratropium neb 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
103
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ipratropium/
albuterol soln. 1
irinotecan inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
104
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ISTODAX INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
105
OTHER
CRITERIA

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
itraconazole cap 1
DRUG
TIER
LEVEL
COVERED
USES
All FDAapproved
indications not
otherwise
excluded from
Part D. Tinea
corporis.
Tinea cruris,
faciei,
manuum,
imbricata, and
pedis
(nonmoccasin
or chronic
type). Plantaror
moccasintype
dry tinea
pedis. Tinea or
pityriasis
versicolor.
Tinea capitis.
Tinea barbae.
Treatment of
vaginal
candidiasis.
Prevention of N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Onychomycosis must be
judged to be medically
significant (causing
impaired mobility,
discomfort, or in the
presence of diabetes
mellitus, an
immunocompromised
condition) by the
treating physician and a
positive KOH, fungal
culture, DTM culture,
nail biopsy, or histologic
examination (PAS) is
required before therapy
initiation. Before a
second course of
treatment is permitted
for onychomycosis, a
culture must demonstrate
a fungal infection. Use
of topical ciclopirox 8%
solution with
itraconazole is not
permitted. Itraconazole
should not be given for N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
N/A
COVERAGE
DURATION
Ony=12wks
toenails,8wks
fingernails.Cand
ida ony,4
mos.Other
conds=12mos.
OTHER
CRITERIA
Tinea corporis
after a trial of a
topical
antifungal agent,
except for
extensive
conditions.
Tinea cruris,
faciei, manuum,
imbricata, and
pedis
(nonmoccasin or
chronic type)
after a trial of a
topical
antifungal agent.
Tinea or
pityriasis
versicolor after
trial of a topical
antifungal agent,
except for
extensive
conditions.
Treatment of
vaginal
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
recurrent
vulvovaginal
or vaginal
candidiasis.
Treatment or
prevention of
other
superficial,
systemic or
suspected
fungal
infections.
Patient has
been started
and stabilized
on intravenous
(IV)
itraconazole
therapy or oral
itraconazole
for a systemic
infection and
it is being
used as
continuation
therapy.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
the treatment of
onychomycosis in
patients with CHF.
Itraconazole is permitted
for the treatment of
patients with Candida
onychomycosis if they
have a culture positive
for Candida.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
candidasis after
a trial of oral
fluconazole.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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FORMULARY
DRUG
BRAND NAME
generic name
IXEMPRA INJ 2
JAKAFI TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Candida
onychomycosi
s.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. All
medically N/A N/A N/A
Restricted to or in
consult with
Oncology
Specialists.
Approved for
duration of
contract year
subject to
formulary
change and
member
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
N/A

FORMULARY
DRUG
BRAND NAME
generic name
JEVTANA INJ. 2
KALYDECO
TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
accepted
eligibility.
indications not
otherwise
excluded from
Part D
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from N/A N/A N/A
Restricted to or in
consult with
Pulmonology
Specialist.
Approved for
duration of
contract year
subject to
formulary
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
N/A

FORMULARY
DRUG
BRAND NAME
generic name
KEPIVANCE
INJ 2
KINERET INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
Part D. All
medically
accepted
indications not
otherwise
excluded from
Part D
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
change and
member
eligibility.
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
Rheumatoid
Approved for
arthritis (RA) and
duration of
indications not N/A
N/A
Still's disease, N/A
contract year
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
Adults with RA.
Tried
adalimumab,

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
otherwise
excluded from
Part D.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
adults.
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
subject to
formulary
change and
member
eligibility.
OTHER
CRITERIA
certolizumab
pegol,
golimumab,
etanercept, or
infliximab for at
least 2 months
or was intolerant
to one of these
therapies.
JIA/JRA
(regardless of
onset), approve
if patient has
tried etanercept,
adalimumab,
infliximab, or
abatacept for at
least 2 months
or was intolerant
to one of these
therapies.
Systemic onset
of JIA, approve
if patient has
tried a systemic
corticosteroid
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
(CS).
Ankylosing
spondylitis,
approve if the
patient has tried
etanercept,
infliximab,
golimumab, or
adalimumab for
at least 2 months
or was intolerant
to one of these
therapies. SD,
approve if
patient has tried
a CS and has
had an
inadequate
response to 1
non-biologic
DMARD (eg,
methotrexate)
for at least 2
months or was
intolerant to this
therapy. MWS,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
approve if
patient has tried
two other drugs
(rilonacept,
canakinumab,
colchicine, CS,
chlorambucil,
antihistamines,
dapsone,
azathioprine,
mycophenolate
mofetil) for
MWS. FCAS,
approve if
patient has tried
two other drugs
(eg, colchicine,
CS,
antihistamines,
azathioprine,
mycophenolate
mofetil,
rilonacept, or
canakinumab)
for FCAS.
Schnitzler's
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
113

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
syndrome,
approve if
patient has tried
one other
prescription
medication used
in Schnitzler's
syndrome (eg,
NSAIDs,
antihistamines,
colchicine, CS,
immunosuppres
sive drugs).
Acute gout,
patient has tried
2 standard
therapies for
acute gout (eg,
NSAIDs,
colchicine, CS)
or patient cannot
tolerate or has
contraindication
s to standard
therapies. FMF,
approve in
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
114

FORMULARY
DRUG
BRAND NAME
generic name
LETAIRIS TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D.
Patients
currently on
Letairis or
Tracleer for
treatment of
pulmonary
arterial
hypertension. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For the FDA-approved
indication of pulmonary
arterial hypertension,
patients not currently on
Letairis or Tracleer are
required to have had a
right-heart
catheterization to
confirm the diagnosis of
PAH to ensure
appropriate medical
assessment. For the
FDA-approved
indication of pulmonary
arterial hypertension,
patients currently on
Letairis or Tracleer may
continue therapy if they
have a diagnosis of N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
For treatment of
pulmonary arterial
hypertension,
Letairis or Tracleer
must be prescribed
by or in
consultation with a
cardiologist or a
pulmonologist.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
115
OTHER
CRITERIA
patients who
have tried
colchicine.
TRAPS,
approve in
patients who
have tried CS.
Digital ulcers,
approve
Tracleer if the
patient has tried
two other
therapies for this
condition such
as calcium
channel blockers
(eg, amlodipine,
felodipine,
isradipine,
nifedipine),
alpha-adrenergic
blockers (eg,
prazosin),
nitroglycerin,
phosphodiestera
se-5 inhibitors

FORMULARY
DRUG
BRAND NAME
generic name
LEUKINE INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
116
OTHER
CRITERIA
PAH.
(eg, sildenafil,
vardenafil), or
angiotensinconverting
enzyme
inhibitors (ACE
inhibitors), or
the patient has
tried one
vasodilator
product (eg,
intravenous
epoprostenol,
intravenous
alprostadil).
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
leuprolide inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D but
specific to the
following
drugs as
follows:
Prostate
cancer
(Lupron Depot
OR Eligard),
Endometriosis
(Lupon
Depot),
Uterine
leiomyomata
(Lupon
Depot), N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
117
OTHER
CRITERIA
Premenstrual
syndrome
(PMS) for
patients that
have tried two
other therapies
(e.g., selective
serotonin
reuptake
inhibitors
[SSRIs], oral
contraceptives
[OCs]).
For
Menstrual
dysfunctional migraine
uterine bleeding approve if the
approve for up patient has tried
to 6 months and two other
all other therapies for the
indications x 12 treatment of
mos. acute migraine

FORMULARY
DRUG
BRAND NAME
generic name
levalbuterol neb 1
levocarnitine inj. 1
DRUG
TIER
LEVEL
COVERED
USES
Treatment of
central
precocious
puberty
(Lupron Depot
Ped).
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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118
OTHER
CRITERIA
(e.g., NSAIDs,
triptans,
ergotamines) or
prophylaxis of
migraine (e.g.,
beta-blockers,
amitriptyline,
divalproex).

FORMULARY
DRUG
BRAND NAME
generic name
levocarnitine
soln. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
119
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
levocarnitine tab 1
LIDODERM
PATCH 2
DRUG
TIER
LEVEL
COVERED
USES
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
Authorization
indications not
will be for 12
otherwise
months, unless
excluded from
otherwise
Part D. N/A N/A N/A N/A
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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120
OTHER
CRITERIA
Myofascial pain
as adjunctive
therapy.
Approve if
being used in
combination

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
with a standard
myofascial
trigger point
(MTP) treatment
modalities (e.g.,
physical
therapy, MTP
injections of
local anesthetic,
relaxation
techniques).
Low back pain.
Approve after
trying two other
pharmacologic
therapies
commonly used
to treat low back
pain (e.g.,
acetaminophen,
nonsteroidal
antiinflammatory
agents
[NSAIDs],
muscle
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
121

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
relaxants,
opioids,
cyclooxygenase-
2 [COX-2]
inhibitors,
tramadol,
gabapentin,
tricyclic
antidepressants
[amitriptyline]).
OA, approve
after trying at
least two other
pharmacologic
therapies (e.g.,
acetaminophen,
COX-2
inhibitors,
NSAIDs,
salicylates,
tramadol,
opioids,
intraarticular
glucocorticoids,
topical
capsaicin,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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122

FORMULARY
DRUG
BRAND NAME
generic name
LIPOSYN III
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
123
OTHER
CRITERIA
topical
methylsalicylate
, or intraarticular
hyaluronan).
Carpal tunnel
syndrome.
Approve after a
trying one other
pharmacological
therapy used to
treat carpal
tunnel syndrome
(e.g., steroids
[oral or
injectable],
NSAIDs).
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
LUPRON
DEPOT INJ.
3.75MG 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D but
specific to the
following
drugs as
follows:
Prostate
cancer
(Lupron Depot
OR Eligard),
Endometriosis
(Lupon
Depot),
Uterine
leiomyomata
(Lupon N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
124
OTHER
CRITERIA
Premenstrual
syndrome
(PMS) for
patients that
have tried two
other therapies
(e.g., selective
serotonin
reuptake
inhibitors
[SSRIs], oral
contraceptives
For
[OCs]).
dysfunctional Menstrual
uterine bleeding migraine
approve for up approve if the
to 6 months and patient has tried
all other two other
indications x 12 therapies for the
mos. treatment of

FORMULARY
DRUG
BRAND NAME
generic name
LUPRON
DEPOT INJ.
7.5MG, 22.5MG,
30MG, 45MG 2
DRUG
TIER
LEVEL
COVERED
USES
Depot),
Treatment of
central
precocious
puberty
(Lupron Depot
Ped).
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D but
specific to the
following
drugs as
follows:
Prostate
cancer
(Lupron Depot
OR Eligard),
Endometriosis
(Lupon
Depot), N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
125
OTHER
CRITERIA
acute migraine
(e.g., NSAIDs,
triptans,
ergotamines) or
prophylaxis of
migraine (e.g.,
beta-blockers,
amitriptyline,
divalproex).
Premenstrual
syndrome
(PMS) for
patients that
have tried two
other therapies
(e.g., selective
serotonin
reuptake
For
inhibitors
dysfunctional [SSRIs], oral
uterine bleeding contraceptives
approve for up [OCs]).
to 6 months and Menstrual
all other migraine
indications x 12 approve if the
mos. patient has tried

FORMULARY
DRUG
BRAND NAME
generic name
LUPRON
DEPOT
PEDIATRIC
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
Uterine
leiomyomata
(Lupon
Depot),
Treatment of
central
precocious
puberty
(Lupron Depot
Ped).
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D but
specific to the
following
drugs as
follows:
Prostate
cancer
(Lupron Depot
OR Eligard), N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
126
OTHER
CRITERIA
two other
therapies for the
treatment of
acute migraine
(e.g., NSAIDs,
triptans,
ergotamines) or
prophylaxis of
migraine (e.g.,
beta-blockers,
amitriptyline,
divalproex).
Premenstrual
syndrome
(PMS) for
patients that
have tried two
other therapies
For
(e.g., selective
dysfunctional serotonin
uterine bleeding reuptake
approve for up inhibitors
to 6 months and [SSRIs], oral
all other contraceptives
indications x 12 [OCs]).
mos. Menstrual

FORMULARY
DRUG
BRAND NAME
generic name
melphalan inj. 2
DRUG
TIER
LEVEL
COVERED
USES
Endometriosis
(Lupon
Depot),
Uterine
leiomyomata
(Lupon
Depot),
Treatment of
central
precocious
puberty
(Lupron Depot
Ped).
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
127
OTHER
CRITERIA
migraine
approve if the
patient has tried
two other
therapies for the
treatment of
acute migraine
(e.g., NSAIDs,
triptans,
ergotamines) or
prophylaxis of
migraine (e.g.,
beta-blockers,
amitriptyline,
divalproex).

FORMULARY
DRUG
BRAND NAME
generic name
methocarbamol
tab 1
methotrexate inj 1
DRUG
TIER
LEVEL
COVERED
USES
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 1
month.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
128
OTHER
CRITERIA
Musculoskeletal
conditions/disor
ders, approve if
the patient has
tried two other
therapies for the
current
condition.

FORMULARY
DRUG
BRAND NAME
generic name
methotrexate tab 1
MIACALCIN
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
129
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
mitomycin inj. 1
mitoxantrone inj 1 This drug may N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
130
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
modafanil tab 1
DRUG
TIER
LEVEL
COVERED
USES
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For the FDA-approved
indication of excessive
sleepiness due to
obstructive sleep
apnea/hypoapnea
syndrome (OSAHS)
patients must have tried
continuous positive
airway pressure (CPAP).
For the FDA-approved
indication of excessive
AGE
RESTRICTION
ADHD or ADD in
patients less than
18 years.
Adjunctive
augmentation
treatment for
depression must be
in adults.
PRESCRIBER
RESTRICTION
Idiopathic
hypersomnia must
have the diagnosis
confirmed by a
sleep specialist
physician or at an
institution that
specializes in sleep
disorders.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
131
OTHER
CRITERIA
Excessive
sleepiness due
to OSAHS if the
patient has tried
CPAP.
Excessive
sleepiness due
to SWSD if the
patient is
working at least
5 overnight

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
sleepiness due to shiftwork
sleep disorder
(SWSD), patients must
be working at least 5
overnight shifts per
month.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
shifts per month.
ADHD/ADD
who have tried
two alternative
medications for
ADHD/ADD
from two
different classes
as follows:
methylphenidate
products (e.g.,
methylphenidate
,
dexmethylpheni
date),
amphetamines
(e.g., mixed
amphetamine
salts,
dextroamphetam
ine),
atomoxetine,
bupropion or
tricyclic
antidepressants
(TCAs e.g.,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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132

FORMULARY
DRUG
BRAND NAME
generic name
MOZOBIL INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
133
OTHER
CRITERIA
imipramine,
desipramine).
Adjunctive/aug
mentation
treatment for
depression in
adults if the
patient is
concurrently
receiving other
medication
therapy for
depression.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
mycophenolate
cap 1
mycophenolate
tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
134
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
MYFORTIC
TAB 2
NAGLAZYME 2 This drug may N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
135
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
INJ.
NEPHRAMINE
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
136
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Cancer patients
receiving
chemotherapy, if
prescribed by or in
consultation with
an oncologist or
hematologist.
Radiation injury, if
prescribed by, or in
COVERAGE
DURATION
All FDAapproved
indications not
otherwise
excluded from
Part D but
worded more
broadly as
Radiation injury,
approve if the estimated
whole body or
significant partial-body
exposure is at least 3
Grays in adults aged less
than 60 years, or at least
2 Grays in children
consultation with, a
NEULASTA
cancer patients
receiving
myelosuppress
ive
(aged 12 years or less) or
in adults aged 60 years
or older, or in those who
have major trauma
physician with
experience in
treating acute
radiation
Authorization
will be for 12
months, unless
otherwise
INJ. 2 chemotherapy. N/A
injuries or burns. N/A
syndrome. specified.
NEUMEGA INJ. 2 This drug may N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
137
OTHER
CRITERIA
Radiation
injury, approve
if the estimated
whole body or
significant
partial-body
exposure is at
least 3 Grays in
adults aged less
than 60 years, or
at least 2 Grays
in children
(aged 12 years
or less) or in
adults aged 60
years or older,
or in those who
have major
trauma injuries
or burns.

FORMULARY
DRUG
BRAND NAME
generic name
NEUPOGEN
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D worded
more broadly
as cancer
patients
receiving
myelosuppressN/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Radiation injury,
approve if the estimated
whole body or
significant partial-body
exposure is at least 3
Grays in adults aged less
than 60 years, or at least
2 Grays in children
(aged 12 years or less) or
in adults aged 60 years
or older, or in those who N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Cancer/AML,
PBPC, MDS, AA,
ALL, oncologist or
a hematologist.
SCN, hematologist.
HIV/AIDS
neutropenia,
infectious disease
(ID) physician
(MD),
hematologist, or
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
138
OTHER
CRITERIA
Radiation
injury, approve
if the estimated
whole body or
significant
partial-body
exposure is at
least 3 Grays in
adults aged less
than 60 years, or
at least 2 Grays

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
ive
chemotherapy,
patients with
acute myeloid
leukemia
(AML)
receiving
chemotherapy,
cancer patients
receiving bone
marrow
transplantation
(BMT),
patients
undergoing
peripheral
blood
progenitor cell
(PBPC)
collection and
therapy, and
patients with
severe chronic
neutropenia
[SCN] (e.g.,
congenital
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
have major trauma
injuries or burns.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
MD specializing in
HIV/AIDS. RI, an
MD with
experience in
treating acute
radiation
syndrome. RT, an
oncologist,
radiologist, or
radiation
oncologist.
COVERAGE
DURATION
OTHER
CRITERIA
in children
(aged 12 years
or less) or in
adults aged 60
years or older,
or in those who
have major
trauma injuries
or burns.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
139

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
neutropenia,
cyclic
neutropenia,
idiopathic
neutropenia).
Neutropenia
associated
with human
immunodefici
ency virus
(HIV) or
acquired
immunodefici
ency
syndrome
(AIDS).
Treatment of
myelodysplast
ic syndromes
(MDS). Drug
induced
agranulocytosi
s or
neutropenia.
Aplastic
anemia (AA).
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
140

FORMULARY
DRUG
BRAND NAME
generic name
NEXAVAR
TAB 2
NUEDEXTA
CAP 2
ondansetron inj 1
DRUG
TIER
LEVEL
COVERED
USES
Acute
lymphocytic
leukemia
(ALL).
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
All FDAapproved
indications not
otherwise
excluded from
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Prescribed by a
Oncologist or
Require patient to under the direct
be at least 18 years consultation of an
old.
Oncologist.
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
Authorization
will be for 12
months.
Part D. N/A N/A N/A N/A
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
141
OTHER
CRITERIA
N/A

FORMULARY
DRUG
BRAND NAME
generic name
ondansetron odt
tab 1
ondansetron
soln. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
142
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ondansetron tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
143
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ONFI TAB 2
ONTAK INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDA
approved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Prior Authorization
required for
members 65 and
older
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
144
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
ORENCIA INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. Plus
patients who
have already
been started
on abatacept
for a covered
use. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Rheumatoid
arthritis (RA),
adults.
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
145
N/A
Authorization
will be for 12
months, unless
otherwise
specified.
OTHER
CRITERIA
RA, approve if
the patient has
tried one of the
following
biologic
DMARDs,
adalimumab,
etanercept,
certolizumab
pegol,
golimumab, or
infliximab for at
least 2 months,
or was intolerant
to one of these
therapies.
Juvenile
idiopathic
arthritis (JIA)
[or Juvenile
Rheumatoid
Arthritis (JRA)],
polyarticular
course, approve

FORMULARY
DRUG
BRAND NAME
generic name
orphenadrine
compound ds tab 1
orphenadrine
citrate er tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 1
month.
Authorization
will be for 1
month.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
if the patient has
tried one of the
following
biologic
DMARDs,
adalimumab,
etanercept, or
infliximab for at
least 2 months
or was intolerant
to one of these
therapies.
Musculoskeletal
conditions/disor
ders, approve if
the patient has
tried two other
therapies for the
current
condition.
Musculoskeletal
conditions/disor
ders, approve if
the patient has
tried two other
therapies for the

FORMULARY
DRUG
BRAND NAME
generic name
orphenadrine/asp
irin/caffeine 1
oxaliplatin inj 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 1
month.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
current
condition.
Musculoskeletal
conditions/disor
ders, approve if
the patient has
tried two other
therapies for the
current
condition.

FORMULARY
DRUG
BRAND NAME
generic name
paclitaxel inj 1
pamidronate inj 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
PEGASYS INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Hepatitis C. depending
on genotype, response in
HCV RNA, liver
fibrosis, HIV status, and
HIV RNA. Chronic Hep
C, on waiting list for
liver transplant.
Recurrent Hep C, after
liver transplant, grade II
fibrosis or greater. N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
For all pts with
hepatitis C, must
be prescribed by an
infectious disease
MD,
gastroenterologist,
hepatologist, or a
transplant MD or
in consultation
with one of these
MDs.
COVERAGE
DURATION
Hep C. 12, 24,
48, wks Acute
hep C. 6 to 12
mo Chronic hep
C lvr trnplnt 12
wks non-hep C
12 mo
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
Adult not
previously txd
for chronic
hepatitis C (HC)
w/ interferon
alfa
(IA)/peginterfer
on alfa (PA) and
not HIV coinfected,HC
genotype 2/3
authorize 24
wks initial tx, or
HC genotype 3
w/ high level of
HCV RNA (per
MD) or
advanced
fibrosis
authorize 48

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
wks (total), or
HC genotypes
1/4 authorize 12
wks initial tx
(document
baseline HCV
RNA) and
reassess viral
titer at 12 wks,
if decreased by
2log10 or more
and virus is
undetectable,
authorize 36
wks (total 48
wks), or if not
decreased by
2log 10,
authorize 12
wks and
reassess at 24
wks, or
genotype 1 w/
viral titer
decrease of
2log10 but virus
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
still detectable,
authorize 12
wks and
reassess at 24
wks. At 24 wk,
if advanced
fibrosis (via
liver bx) and
undetectable
virus, authorize
24 wks (48 wks
total), or if
advanced
fibrosis and
detectable HCV
RNA MD and pt
to decide
whether to cont
w/ another 24
wks OR If no
advanced
fibrosis and do
not have greater
than or equal to
2 log10 decrease
or virus
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
undetectable, no
further
authorization, or
if genotype 1 w/
2log10 decrease
AND detectable
virus at wk 12
but no
detectable virus
at wk 24, then
authorize for 48
wksHC viral
genotype 5/6
use genotype
1/4 criteria
above.Coinfecte
d with HIV/HC
(genotype
1,2,3,4) and not
previously txd
for HC,
authorize up to
48 wks
(total).Child 2 to
17 yrs w/HC
(genotypes
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
1,2,3,4) not been
previously txd
for HC w/IA/PA
AND not HIV
co-infected,
authorize 24
wks initial tx. At
24 wk, if viral
titer
undetectable
after 24 wks or
if viral titer
decreased by
2log10 or more
after 12 wks of
tx, authorize 24
wks (48 wks
total), or if viral
titer still
detectable after
24 wks of tx,
then no further
authorization.Co
infected w/ HC
and Hep B,
authorize 48
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
wks. Acute hep
C (ie, infection
within 6 mos of
exposure),
authorize 6 to 12
mos of tx if at
least 2 to 4 mos
after acute
onset.Retreatme
nt of pts who
have been
previously txd
for HC w/ IA or
PA, authorize 48
wks.
Retreatment of
pts who failed to
attain a
sustained
virologic
response (SVR)
[undetectable
HCV RNA at
the end of
txment and 24
wks after txment
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
completion] w/
PA and ribavirin
is not
recommended
unless specific
factors that
contributed to
the nonresponse
are identified
and corrected
before retxment.
Recurrent hep C
after liver
transplant and
grade II fibrosis,
authorize 48
wks if PA
prescribed by
hepatologist or
liver transplant
MD affiliated w/
liver transplant
program.HC on
waiting list for
liver
transplantation,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
authorize initial
12 wks if
administered in
liver clinic
affiliated with
liver transplant
program. At 12
wks, genotype
2/3 and viral
titer decreased
by 2log10 or
more and virus
undetectable
authorize 24
wks total from
the time pt has
achieved an
optimal dose of
PA and
ribavirin, for
genotype 1 and
viral titer
decreased by
2log10 or more
and virus
undetectable
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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156

FORMULARY
DRUG
BRAND NAME
generic name
pentostatin inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
157
OTHER
CRITERIA
authorize 52
wks total from
the time pt has
achieved an
optimal dose of
PA and
ribavirin, or
genotype 1/2/3
and viral titer
not decreased by
2log10, then no
further
authorization.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
PERFOROMIST
NEB 2
PERJETA INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
Approved for
duration of
contract year
subject to
formulary
change and
member
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
N/A

FORMULARY
DRUG
BRAND NAME
generic name
POTIGA TAB 2
PRADAXA
CAP 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. Plus
use in patients
with atrial
flutter.
Treatment of
acute venous
thromboembol
ism.
Prevention of
venous
thromboembol
ism after hip N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
eligibility.
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
Authorization
will be for 12
months.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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159
OTHER
CRITERIA
N/A
Authorize use of
Pradaxa for
patients with
non-valvular
atrial fibrillation
or flutter.
Authorization
may be given
for treatment of
acute venous
thromboembolis
m (VTE),
prevention of
VTE after hip or
knee
replacement
surgery, or

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
replacement
surgery.
Prevention of
venous
thromboembol
ism after knee
replacement
surgery.
Additional
indications
will be
evaluated by a
pharmacist
and/or a
physician on a
case-by-case
basis.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
additional
indications
evaluated by a
pharmacist
and/or a
physician on a
case-by-case
basis, if the
patient has tried
one of the
following
therapies for the
condition:
warfarin
(Coumadin),
fondaparinux
(Arixtra), or a
low molecular
weight heparin
(LMWH)
product
(enoxaparin
[Lovenox],
tinzaparin
[Innohep],
dalteparin
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
[Fragmin]), OR
if the patient is
unable to take
one of these
medications
listed for the
condition for
one of the
following
reasons: patient
has allergic,
immunologic or
inherited
disorder, patient
had adverse
effect (eg, major
organ toxicity,
major bleeding),
the patient has
experienced
ineffectiveness
to the agent in a
prior setting, the
patient has drugdrug
interactions
that cannot be
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
managed
(warfarin), the
patient lacks
access to proper
monitoring
(warfarin), the
patient has
experienced
prior heparininduced
thrombocytopen
ia (HIT) or
heparin-induced
thrombocytopen
ia and
thrombosis
(HITT)
(fondaparinux
[Arixtra] or
LMWH), or the
patient is unable
to perform
injections or
have injections
administered to
them
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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162

FORMULARY
DRUG
BRAND NAME
generic name
premasol soln. 2
PROCALAMIN
E INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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163
OTHER
CRITERIA
(fondaparinux
[Arixtra] or
LMWH).
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
PROCRIT INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D worded
as anemia
associated
with chronic
renal failure
(CRF),
including
patients on
dialysis and
not on
dialysis, and
worded as N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
CRF
anemia.Hemoglobin
(Hb) of less than or
equal to 10.0 g/dL to
start.Hb less than or
equal to 12.0 g/dL if
previously on epoetin
alfa (EA) or
Aranesp.Anemia
w/myelosuppressive
chemotx.Hb
immediately prior to EA
is 10.0 g/dL or less (or
hematocrit [Hct] is 30%
or less).EA maintenance
is starting dose if Hb
level remains 10.0 g/dL N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
AA, prescribed by
a hematologist.
COVERAGE
DURATION
Preop approval:
1 month. All
others initial
appr 3months.
Reauth at 3
month intervals
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
Part B versus
Part D
determination
will be made at
time of prior
authorization
review per CMS
guidance to
establish if the
drug prescribed
is to be used for
an end-stage
renal disease
(ESRD)-related
condition.
Anemia
secondary to

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
anemia
secondary to
myelosuppress
ive anticancer
chemotherapy
in solid
tumors,
multiple
myeloma,
lymphoma,
and
lymphocytic
leukemia. Plus
anemia in
patients with
HIV who are
receiving
zidovudine.
Anemic
patients (Hb of
13.0 g/dL or
less) at high
risk for
perioperative
transfusions
(secondary to
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
or less (or Hct remains
30% or less) 4 wks after
start and Hb rise is 1.0
g/dL or more (Hct rise is
3% or more).Pts w/Hb
rises less than 1.0 g/dL
(Hct rise less than 3%)
vs pretx baseline over 4
wks of tx and Hb is less
than 10.0 g/dL after 4
wks of tx (Hct is less
than 30%), the
recommended FDA
starting dose may be
increased once by
25%.Continued use is
not reasonable/necessary
if Hb rises less than 1.0
g/dL (Hct rise less than
3%) vs pretx baseline by
8 wks of tx.Continued
EA is not
reasonable/necessary if
there is a rapid Hb rise
more than 1.0 g/dL (Hct
more than 3%) over 2
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
myelosuppressiv
e anticancer
chemotherapy in
solid tumors,
multiple
myeloma,
lymphoma, and
lymphocytic
leukemia. Pts
with Hb rise of
less than 1.0
g/dL (or Hct 3%
or less) and Hb
levels is less
than 10.0 g/dL
after 4 wks
therapy, the
recommended
FDA dose may
be increased
once by 25%.
Continued
epoetin alfa use
is not reasonable
or necessary if
the Hb rise is
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
significant,
anticipated
blood loss and
are scheduled
to undergo
elective,
noncardiac,
nonvascular
surgery to
reduce the
need for
allogeneic
blood
transfusions).
Anemia due to
myelodysplast
ic syndrome
(MDS).
Anemia
associated
with use of
ribavirin
therapy for
hepatitis C (in
combination
with interferon
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
wks of tx unless Hb
remains below or
subsequently falls to less
than 10.0 g/dL (or Hct is
less than
30%).Continuation/reins
titution of EA must have
dose reduction of 25% of
previous dose. MDS,
approve if Hb is 12.0
g/dL or less.Previously
receiving Aranesp or
EA, approve if Hb is
12.0 g/dL or less. An
additional 6 months
allowed after first 6
months if Hb is 12.0
g/dL or less. Anemia in
HIV (with or without
zidovudine), Hb is 10.0
g/dL or less or
endogenous
erythropoetin levels are
500 munits/mL or less at
tx start.Previously on EA
approve if Hb is 12.0
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
less than 1.0
g/dL (or Hct is
less than 3%)
compared to
pretreatment
baseline by 8
weeks of
treatment.
Continued
epoetin alfa
administation is
not reasonable
and necessary if
there is a rapid
rise in Hb or
more than 1.0
g/dL (or Hct
more than 3%)
over 2 weeks of
treatment unless
the Hb remains
below or
subsequently
falls to less than
10.0 g/dL (or
Hct less than
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
or pegylated
interferon alfa
2a/2b
products).
Anemia in
HIV-infected
patients.
Anemia in
heart failure
(HF).
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
g/dL or less.Anemia due
to ribavirin for Hep C,
Hb is 10.0 g/dL or less at
tx start. All conds, deny
if Hb exceeds 12.0 g/dL.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
30%).
Continuation
and reinstitution
of epoetin alfa
must include a
dose reduction
of 25% from the
previously
administered
dose.
Continuation
and reinstitution
of Aranesp must
include a dose
reduction of
25% from the
previously
administered
dose. Anemia in
HF, approve
initial trial of up
to 2 months for
patients with
more severe HF,
Hb of 10.0 g/dL
or less, anemia
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
persists despite
transfusions or
pt has
contraindication
s to transfusions.
Deny if Hb is
more than 12.0
g/dL. Further
approval after
initial course
will be
determined on a
case-by-case
basis after
evaluation by a
pharmacist
and/or
physician.
Anemia of
chronic disease,
approve initial
trial of 3 months
for patients with
symptomatic
anemia of 10.0
g/dL or less,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
anemia persists
despite
transfusions or
cannot tolerate
or undergo
transfusions,
and/or low
erythropoietin
levels ot failure
of other
treatment
modalities (eg,
iron
supplementation
). Other causes
of anemia have
been ruled out.
Deny if Hb is
more than 12.0
g/dL. Further
approval after
initial course
will be
determined on a
case-by-case
basis after
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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169

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
evaluation by a
pharmacist
and/or
physician.
Treatment of
AA, approve
initial trial of up
to 1 month for
patients with
symptomatic
anemia of less
than 11.0 g/dL.
Deny if Hb is
more than 12.0
g/dL. Further
approval after
initial course
will be
determined on a
case-by-case
basis after
evaluation by a
pharmacist
and/or
physician.
PROGRAF INJ 2 This drug may N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
PROLASTIN
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D. Alpha-
1 antitrypsin
(AAT)
deficiencyassociated
panniculitis. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
For AAT deficiency
with emphysema (or
COPD), approve in
patients with baseline
(pretreatment) alpha1-
antitrypsin serum
concentration less than
11 microM (11
micromol/L) or 80
mg/dL. N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
For all covered
uses, the patient
is required to try
Aralast NP first
line. For AAT
deficiency with
emphysema (or
COPD), approve
in patients with
baseline
(pretreatment)

FORMULARY
DRUG
BRAND NAME
generic name
PROMACTA
TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D.
Thrombocytop
enia due to
hepatitis C
virus (HCV)-
related
cirrhosis. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Cause of
thrombocytopenia.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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172
N/A
Treatment of
thrombocytopenia
due to chronic
immune
(idiopathic)
thrombocytopenic
purpura (ITP),
approve if
prescribed by, or
after consultation
with, a
hematologist.
Treatment of
thrombocytopenia
due to HCVrelated
cirrhosis,
approve if
prescribed by, or
Authorization
will be for 12
months.
OTHER
CRITERIA
alpha1-
antitrypsin
serum
concentration
less than 11
microM (11
micromol/L) or
80 mg/dL.
For treatment of
thrombocytopen
ia due to HCVrelated
cirrhosis,
approve to allow
for initiation of
antiviral
therapy.

FORMULARY
DRUG
BRAND NAME
generic name
promethazine
syrup 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
after consultation
with, either a
gastroenterologist
or a physician who
specializes in
infectious disease.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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173
OTHER
CRITERIA
Approve if the
patient has tried
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,
desloratadine,
levocetirizine,
fexofenadine/ps
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current
condition.
Approve
promethazine

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral
anti-emetic
agent
(ondansetron,
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
diphenhydramin
e (capsules or
elixir) if the
patient has tried
at least two
other FDAapproved
products for the
management of
insomnia.
Approve
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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FORMULARY
DRUG
BRAND NAME
generic name
promethazine tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Patients aged less
than 65 years,
approve. Patients
aged 65 years and
older, other criteria
apply.
N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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175
OTHER
CRITERIA
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
pamoate
(capsules) if the
patient has tried
at least two
other FDAapproved
products for the
management of
anxiety.
Approve if the
patient has tried
a prescription
oral second
generation
antihistamine
product
(cetirizine,
fexofenadine,
desloratadine,
levocetirizine,
fexofenadine/ps

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
eudoephedrine,
or
desloratadine/ps
eudoephedrine)
for the current
condition.
Approve
promethazine
hydrochloride
tablets or syrup
if the patient has
tried a
prescription oral
anti-emetic
agent
(ondansetron,
granisetron,
dolasetron,
palonosetron,
aprepitant) for
the current
condition.
Approve
diphenhydramin
e (capsules or
elixir) if the
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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176

FORMULARY
DRUG
BRAND NAME
generic name
PROVIGIL
TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For the FDA-approved
indication of excessive
sleepiness due to
obstructive sleep
AGE
RESTRICTION
ADHD or ADD in
patients less than
18 years.
Adjunctive
PRESCRIBER
RESTRICTION
Idiopathic
hypersomnia must
have the diagnosis
confirmed by a
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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177
OTHER
CRITERIA
patient has tried
at least two
other FDAapproved
products for the
management of
insomnia.
Approve
hydroxyzine
hydrochloride
(tablets and
syrup) or
hydroxyzine
pamoate
(capsules) if the
patient has tried
at least two
other FDAapproved
products for the
management of
anxiety.
Excessive
sleepiness due
to OSAHS if the
patient has tried

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
excluded from
Part D.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
apnea/hypoapnea
syndrome (OSAHS)
patients must have tried
continuous positive
airway pressure (CPAP).
For the FDA-approved
indication of excessive
sleepiness due to shiftwork
sleep disorder
(SWSD), patients must
be working at least 5
overnight shifts per
month.
AGE
RESTRICTION
augmentation
treatment for
depression must be
in adults.
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
sleep specialist specified.
physician or at an
institution that
specializes in sleep
disorders.
OTHER
CRITERIA
CPAP.
Excessive
sleepiness due
to SWSD if the
patient is
working at least
5 overnight
shifts per month.
ADHD/ADD
who have tried
two alternative
medications for
ADHD/ADD
from two
different classes
as follows:
methylphenidate
products (e.g.
methylphenidate
,
dexmethylpheni
date),
amphetamines
(e.g., mixed
amphetamine
salts,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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FORMULARY
DRUG
BRAND NAME
generic name
PULMICORT 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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179
OTHER
CRITERIA
dextroamphetam
ine),
atomoxetine,
bupropion or
tricyclic
antidepressants
(TCAs e.g.,
imipramine,
desipramine).
Adjunctive/aug
mentation
treatment for
depression in
adults if the
patient is
concurrently
receiving other
medication
therapy for
depression.
This drug may
be covered
under
Medicare Part
B or D
depending N/A N/A N/A N/A N/A N/A

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
PULMOZYME
SOLN. 2
RAPAMUNE
SOLN. 2
All FDA
approved
indications not
otherwise
excluded from
Part D. Cystic
Fibrosis N/A N/A N/A N/A
Initial auth for 3
months. May
renew for 3 or 6
months for a Pulmozyme will
total treatment undergo Part B
of 12 months. vs D review.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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180

FORMULARY
DRUG
BRAND NAME
generic name
RAPAMUNE
TAB 2
REBIF INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
N/A N/A N/A
Prescribed by or
after consultation
Authorization
will be for 12
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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181
OTHER
CRITERIA
N/A

FORMULARY
DRUG
BRAND NAME
generic name
REBIF INJ.,
TITRATION
PAK 2
RECLAST INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
indications not
otherwise
excluded from
Part D.
Multiple
Sclerosis
All FDAapproved
indications not
otherwise
excluded from
Part D.
Multiple
Sclerosis N/A N/A N/A
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
with a neurologist
or an MS
specialist.
Prescribed by or
after consultation
with a neurologist
or an MS
specialist.
COVERAGE
DURATION
months, unless
otherwise
specified.
Authorization
will be for 12
months, unless
otherwise
specified.
Authorization
will be for 12
months.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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182
OTHER
CRITERIA
N/A
Reclast may be
approved for the
covered
osteoporosis
indications and
osteogenesis
imperfecta, if 1)
the patient has
tried one oral
bisphosphonate
or oral
bisphosphonate-

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
containing
product AND
the patient has
an inadequate
response as
determined by
the prescribing
physician or the
patient has
intolerability to
an oral
bisphosphonate,
or 2) the patient
cannot take an
oral
bisphosphonate
product because
they cannot
swallow, or
because they
cannot remain in
an upright
position post
oral
bisphosphonate
administration,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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183

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
or because the
patient has a
chronic and
complex
existing
medication
regimen in
which an oral
bisphosphonate
agent will likely
compromise
therapy as
determined by
the prescribing
physician, this
exception will
be evaluated by
a pharmacist
and/or physician
on a case-bycase
basis, or
because the
patient has a
pre-existing
gastrointestinal
medical
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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184

FORMULARY
DRUG
BRAND NAME
generic name
RECOMBIVAX-
HB INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
185
OTHER
CRITERIA
condition (eg,
esophageal
lesions,
esophageal
ulcers, etc.) in
which
intravenous
bisphosphonate
therapy may be
medically
preferred over
oral therapy.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
REGRANEX
GEL 2
DRUG
TIER
LEVEL
COVERED
USES
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. Plus
any
granulating
ulcer/wound
(eg, pressure
ulcers, venous
stasis ulcers)
that is
classified as
NPUAP Stage
III or IV. Any
clean and
granulating
ulcer/wound
classified as
NPUAP Stage
II.
N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Diabetic neuropathic
ulcer(s) that is/are
classified as NPUAP
Stage III or IV. Any
clean and granulating
ulcer/wound classified as
Stage II (e.g., Stage II
diabetic neuropathic
ulcers and pressure
ulcers), III or IV. N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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186
OTHER
CRITERIA
Diabetic
neuropathic
ulcer(s) that
is/are classified
as NPUAP
Stage III or IV.
Any granulating
ulcer/wound
classified as
Stage III or IV.
Any clean and
granulating
ulcer/wound
classified as
Stage II (e.g.,
Stage II diabetic
neuropathic
ulcers and
pressure ulcers),
if the patient has
tried other
standard
ulcer/wound
care therapies

FORMULARY
DRUG
BRAND NAME
generic name
RELISTOR INJ. 2
REMICADE
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
All FDAapproved
indications not
otherwise
excluded from
Part D.
All FDA
approved
indications not
otherwise
excluded from
Part D. Crohn
disease.
Ankylosing
spondylitis.
Plaque
psoriasis.
Rheumatoid
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
N/A
N/A
REQUIRED
MEDICAL
INFORMATION
Initial Therapy: Member
must meet all 3 criteria.
1.Opioid-induced
constipation.
2.Advanced illness
receiving palliative care.
3.Failed 2
laxative/bowel therapies. N/A
Rheumatoid Arthritis.
Tried 1 diseasemodifying
antirheumatic
drug for 2 mos or
concurrently receiving
methotrexate (MTX).
Crohn Disease (CD) for
induction of remission
(IR). Tried corticosteroid
(CS) or CSs
contraindicated or if
currently on CS. CD for
AGE
RESTRICTION
Rheumatoid
arthritis (RA) and
SD, Adults.
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
187
N/A
N/A
OTHER
CRITERIA
(eg,
debridement,
topical therapies
[collagenase])
for at least 4
weeks.
Initial=1
kit.Continuation
of therapy
approved for
duration of
contract year
subject to
member elegi N/A
If
contraindication
s to nearly all
other
tx,exceptions to
be evaluated by
CD (w/ or w/out pharmacist
fistulas)=12 wks and/or MD on
for induction of case-by-case
remission basis. Ulcerative
(IR).All other colitis (UC).
conds=12mos. Tried 2-mo trial

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
Arthritis.
Still’s disease.
Psoriatic
arthritis.
Ulcerative
colitis. Behcet
syndrome
uveitis. Celiac
sprue.
Erythrodermic
psoriasis.
Giant cell
arteritis. Graft
versus host
disease.
Hidradenitis
suppurativa.
Juvenile
idiopathic
arthritis.
Pustular
psoriasis.
Pyoderma
gangrenosum.
Sarcoidosis.
Uveitis.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
maintenance of
remission (MR). Got 3
infliximab (IFB) doses
and responded, or tried
azathioprine (AZA), 6-
mercaptopurine (6MP),
MTX, adalimumab, or
certolizumab pegol.
Fistulizing CD (FCD)
for IR, approve. FCD for
MR. Got 3 doses of IFB
and responded. Plaque
psoriasis (PP). A
minimum body surface
area (BSA) of 5% or
more, exceptions for less
than 5% BSA if PP of
palms, soles, head/neck,
nails, intertriginous areas
or genitalia or
inadequate response to
2-mo trial of topical
therapy (tx) OR
localized phototx
(ultraviolet B [UVB] or
oral methoxsalen plus
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
of systemic CS,
6-MP, AZA,
CSA or
tacrolimus.
Uveitis.Tried
periocular/intrao
cular CS,
systemic CS,
immunosuppres
sant (eg, MTX,
mycophenolate
mofetil, CSA,
AZA,
cyclophosphami
de), etanercept,
adalimumab.
Pyoderma
gangrenosum
(PG).Tried 1
systemic tx (eg,
systemic CS,
immunosuppres
sant (eg, AZA,
6MP, CSA,
cyclophosphami
de,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
188

FORMULARY
DRUG
BRAND NAME
generic name
REMODULIN
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
Wegener
granulomatosi
s.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
UVA light [PUVA]),
and inadequate response
to 2-mo trial of systemic
tx (w/ one of-MTX,
cyclosporine (CSA),
acritretin, adalimumab,
alefacept, etanercept, or
ustekinumab) or
contraindications to all,
and significant disability
or impairment in
physical or mental
functioning according to
treating physician
(MD).Tried systemic tx
(MTX, CSA, acritretin,
etanercept, alefacept,
adalimumab, or
ustekinumab) for 2 mos
or phototx (UVB or
PUVA) for 2 mos.
AGE
RESTRICTION
All FDA
approved
indications not
otherwise
excluded from N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Initial=36
weeks.
Continuation of
therapy
approved for
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
189
OTHER
CRITERIA
chlorambucil),
etanercept or
adalimumab) for
2 mos, or 2-mo
trial of
intralesional CS
or CSA for
localized PG.
Graft versus
host disease
(GVHD).Tried 1
tx (eg, high-dose
CS,
antithymocyte
globulin, CSA,
thalidomide,
tacrolimus,
mycophenolate
mofetil, etc.) or
receiving IFB
concurrently.
N/A

FORMULARY
DRUG
BRAND NAME
generic name
REVATIO TAB 2
RITUXAN INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
Part D.
Pulmonary
arterial
hypertension
(WHO Class
I) with NYHA
Class II, III or
IV symptoms.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For initial approval for
use in pulmonary arterial
hypertension (PAH),
approve if patient has
had a right-heart
catheterization to
confirm diagnosis of
PAH to ensure
appropriate medical
assessment. For patients
currently receiving
sildenafil or tadalafil,
approve if patient has a
diagnosis of PAH. N/A
AGE
RESTRICTION
All FDAapproved
indications not
otherwise N/A N/A RA, adults.
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
duration of
contract year.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
190
OTHER
CRITERIA
For PAH, if Authorization
prescribed by, or in will be for 12
consultation with, a months, unless
cardiologist or a
pulmonologist.
otherwise
specified. N/A
Adult with RA RA.Approve 2 Adult with RA
(initial and repeat doses.16 wks or (initial course),
courses). more after, approve if
Prescribed by a approve 2 more patient has tried

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
excluded from
Part D. All
medicallyaccepted
indications not
otherwise
excluded from
Part D.
Patients
already started
on Rituxan for
rheumatoid
arthritis (RA).
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
rheumatologist or
in consultation
with a
rheumatologist.
Non-RA
indications, if
prescribed by or in
consultation with
an oncologist,
hematologist,
neurologist,
multiple sclerosis
(MS) specialist,
rheumatologist,
dermatologist, or
immunologist, or
who are being
managed by a
transplant center.
COVERAGE
DURATION
doses if
response per
doctor.Othr=12
mos.
OTHER
CRITERIA
at least 1 of the
following
biologic
DMARDs,
etanercept,
certolizumab
pegol,
golimumab,
infliximab, or
adalimumab, for
at least 2
months. Adult
with RA (repeat
course), approve
if 16 weeks or
more after the
first dose of the
previous
rituximab
regimen and the
patient has
responded (eg,
less joint pain,
morning
stiffness, or
fatigue, or
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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191

FORMULARY
DRUG
BRAND NAME
generic name
sildenafil tab 1
SIMPONI 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
All FDAapproved
N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For initial approval for
use in pulmonary arterial
hypertension (PAH),
approve if patient has
had a right-heart
catheterization to
confirm diagnosis of
PAH to ensure
appropriate medical
assessment. For patients
currently receiving
sildenafil or tadalafil,
approve if patient has a
diagnosis of PAH. N/A
AGE
RESTRICTION
For moderate to severe
RA intolerance to or N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
192
OTHER
CRITERIA
improved
mobility, or
decreased soft
tissue swelling
in joints or
tendon sheaths)
as determined
by the
prescribing
physician.
For PAH, if Authorization
prescribed by, or in will be for 12
consultation with, a months, unless
cardiologist or a
pulmonologist.
otherwise
specified. N/A
Approved For members
through duration with a diagnosis

FORMULARY
DRUG
BRAND NAME
generic name
SIMULECT
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
indications not
otherwise
excluded from
Part D.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
failure of therapy with
methotrexate (greater
than 20mg/wk) and 1
DMARD and Enbrel.
Peripheral Ankylosing
Spondylitis or Psoriatic
Arthritis requires failure
of 1 DMARD and
Enbrel.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of contract year
subject to
formulary
change and
member
eligibility.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
193
OTHER
CRITERIA
of early, severeonset
RA,
additional
required medical
information is
not required.
Members with
Axial
Ankylosing
Spondylitis, no
other medical
information is
required.

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
SOMATULINE
DEPOT INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
OTHER
CRITERIA
SPORANOX
SOLN. 2
All FDAapproved
indications not
otherwise
excluded from
Part D. Tinea N/A
Onychomycosis must be
judged to be medically
significant (causing
impaired mobility,
discomfort, or in the
presence of diabetes N/A N/A
Ony=12wks
toenails,8wks
fingernails.Cand
ida ony,4
mos.Other
conds=12mos.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
194
Tinea corporis
after a trial of a
topical
antifungal agent,
except for
extensive

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
corporis.
Tinea cruris,
faciei,
manuum,
imbricata, and
pedis
(nonmoccasin
or chronic
type). Plantaror
moccasintype
dry tinea
pedis. Tinea or
pityriasis
versicolor.
Tinea capitis.
Tinea barbae.
Treatment of
vaginal
candidiasis.
Prevention of
recurrent
vulvovaginal
or vaginal
candidiasis.
Treatment or
prevention of
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
mellitus, an
immunocompromised
condition) by the
treating physician and a
positive KOH, fungal
culture, DTM culture,
nail biopsy, or histologic
examination (PAS) is
required before therapy
initiation. Before a
second course of
treatment is permitted
for onychomycosis, a
culture must demonstrate
a fungal infection. Use
of topical ciclopirox 8%
solution with
itraconazole is not
permitted. Itraconazole
should not be given for
the treatment of
onychomycosis in
patients with CHF.
Itraconazole is permitted
for the treatment of
patients with Candida
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
conditions.
Tinea cruris,
faciei, manuum,
imbricata, and
pedis
(nonmoccasin or
chronic type)
after a trial of a
topical
antifungal agent.
Tinea or
pityriasis
versicolor after
trial of a topical
antifungal agent,
except for
extensive
conditions.
Treatment of
vaginal
candidasis after
a trial of oral
fluconazole.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
195

FORMULARY
DRUG
BRAND NAME
generic name
SPRYCEL TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
other
superficial,
systemic or
suspected
fungal
infections.
Patient has
been started
and stabilized
on intravenous
(IV)
itraconazole
therapy or oral
itraconazole
for a systemic
infection and
it is being
used as
continuation
therapy.
Candida
onychomycosi
s.
All medicallyaccepted
indications not N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
onychomycosis if they
have a culture positive
for Candida.
Diagnosis for which
Sprycel is being used.
For indications of CML N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
196
N/A
Authorization
will be for 12
months.
OTHER
CRITERIA
For CML, new
patient must
have Ph-positive

FORMULARY
DRUG
BRAND NAME
generic name
STREPTOMYCI
N INJ. 1
DRUG
TIER
LEVEL
COVERED
USES
otherwise
excluded from
Part D.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
and ALL, the
Philadelphia
chromosome (Ph) status
of the leukemia must be
reported. New patients
with CML and ALL
which is Ph-positive
may receive
authorization for
Sprycel.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
197
OTHER
CRITERIA
CML for
approval of
Sprycel. For
ALL, new
patient must
have Ph-positive
ALL for
approval of
Sprycel.

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
SUBOXONE SL
FILM 2
SUBOXONE SL
TAB 2
SUTENT CAP 2
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
Renal Cell Carcinoma
and Gastrointestinal
Stromal Tumor in a Sutent requires the
patient who has tried and patient to be at
failed Gleevec. least 18 years old.
PRESCRIBER
RESTRICTION
Sutent requires the
prescriber to be an
Oncologist or
under the direct
consultation of an
Oncologist.
COVERAGE
DURATION
Authorization
will be for 12
months.
Authorization
will be for 12
months.
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
OTHER
CRITERIA
N/A
N/A
N/A
SYMBICORT
INHALER 2
All FDAapproved
indications not
otherwise
excluded from N/A N/A N/A N/A
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
198
N/A

FORMULARY
DRUG
BRAND NAME
generic name
tacrolimus cap 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Part D. Plus
COPD.
Chronic
bronchitis.
Emphysema.
Postinfectious
cough (ie,
cough
persisting after
an acute
respiratory
infection has
resolved).
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
199
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
TASIGNA CAP 2
TAXOTERE
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
of the drug to
make the
determination.
All medicallyaccepted
indications not
otherwise
excluded from
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Diagnosis for which
Tasigna is being used.
For indication of CML,
the Philadelphia
chromosome (Ph) status
of the leukemia must be
reported. New patients
with CML which is Phpositive
may receive
authorization for
Tasigna. N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months.
Part D. N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
200
OTHER
CRITERIA
For CML, new
patient must
have Ph-positive
CML for
approval of
Tasigna.

FORMULARY
DRUG
BRAND NAME
generic name
terbinafine tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D. Tinea
corporis.
Tinea cruris,
faciei,
manuum,
pedis, and
imbricate.
Plantar- or
moccasin-type
dry tinea
pedis. Black
piedra. Tinea
capitis. Tinea
barbae.
Cutaneous
(skin)
candidiasis. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Onychomycosis must be
judged to be medically
significant (causing
impaired mobility,
discomfort, or in the
presence of diabetes
mellitus, an
immunocompromised
condition) by the
treating physician and a
positive KOH, fungal
culture, DTM culture,
nail biopsy, or histologic
examination (PAS) is
required before therapy
initiation. Before a
second course of
treatment is permitted
for onychomycosis, a
culture must demonstrate
a fungal infection. Use
of topical ciclopirox 8% N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
201
N/A
Ony=6wks
fingernails, 12
wks
toenails.Other
conds=12mos.
OTHER
CRITERIA
Tinea corporis if
the patient has
trial a topical
antifungal agent,
except for
extensive
conditions.
Tinea cruris,
faciei, manuum,
pedis, and
imbricate after a
trial of a topical
antifungal agent.
Cutaneous
(skin)
candidiasis after
a trial of a
topical
antifungal agent
and an oral
azole antifungal.
Other superficial

FORMULARY
DRUG
BRAND NAME
generic name
TESTIM GEL 2
TETANUS/
DIPHTHERIA
TOXOID INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
Other
superficial
fungal skin
infections.
All FDAapproved
indications not
otherwise
excluded from
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
solution with terbinafine
is not permitted.
AGE
RESTRICTION
Two morning
testosterone levels fall
below the normal range
for a healthy adult male.
Patient must have tried
and failed
ANDRODERM and
ANDROGEL N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
Part D. N/A
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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202
OTHER
CRITERIA
fungal skin
infections after a
trial of a topical
antifungal agent
or an oral
antifungal agent.

FORMULARY
DRUG
BRAND NAME
generic name
TEV-TROPIN
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
Use in the
management of
acute critical
illness due to
complications of
surgery, trauma,
or with acute
respiratory
failure, as
antiaging
therapy, to
improve
REQUIRED
MEDICAL
INFORMATION
Child/adolesc
documented GH stim
test (levodopa, insulininduced
hypoglycemia,
arginine, clonidine,
glucagon) w/GH
response less than 10
ng/mL AND baseline
height (Ht) less than the
3rd percentile (pct) for
gender/age AND pretx
Ht growth rate (GR)
functional status child less than 3 yrs of
in elderly, less than 7 cm/yr and
somatopause, child greater than or
enhancement of equal to 3 yrs of less
athletic ability, than 4 cm/yr OR child
bone marrow any age GR less than the
transplant 10th pct for age/gender
(BMT) without based on min 6 mos of
total body data.Child w/brain
irradiation, bony radiation does not have
AGE
RESTRICTION
TS, children.
SHOX/CRI/NS,
children/adolescent
s. SGA, 2 to 8 yrs.
HIV failure to
thrive, less than 17
yrs. SBS/HIV
cachexia/wasting,
adults.
PRESCRIBER
RESTRICTION
For adults, the
endocrinologist
must certify that
the somatropin is
not being
prescribed for antiaging
therapy or to
enhance athletic
ability.
Child/adolesc must
be evalaluated by
pediatric
endocrinologist
COVERAGE
DURATION
GH DF 12
mos.SBS 4
wks/yr.Non-GH
DF ISS 6
mos.HIV
wast/cach 24
wks.HIV failure
to thrive 12 wks.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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OTHER
CRITERIA
Adult GH DF
(start),
document
diagnosis of GH
DF due to adultonset
(GH alone
or multiple
hormone
deficiencies/hyp
opituitarism
from pituitary
dz,
hypothalamic
dz, surgery,
cranial radiation
tx, tumor
txment,
traumatic brain
injury, or
subarachnoid
hemorrhage) or
due to

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
dysplasias, burn
injury, cardiac
transplantation,
central
precocius
puberty, chronic
fatigue
syndrome,
congenital
adrenal
hyperplasia,
constitutional
delay of growth
and puberty,
corticosteroidinduced
short
stature including
a variety of
chronic
glucocorticoiddependent
conditions, such
as asthma,
juvenile
rheumatoid
arthritis, after
REQUIRED
MEDICAL
INFORMATION
to meet baseline Ht
crit.Congenital
hypopituitarism does not
have to meet Ht or GR
crit.Child
w/hypophysectomy,
approve.Child/adolesc
GH DF cont tx, GR
increased by 2.5 cm/yr
or more in most recent
yr (MRY) per MD AND
epiphyses open (older
than 12 yrs), both crit
exclude adolesc
w/hypopituitarism.Revie
w GR annually (not
applied to
hypopituitarism).Adoles/
yng adult w/completed
linear growth (GR less
than 2 cm/yr), review for
adult GH DF.Greater
than 18 yrs, auth not
allowed if midparental ht
attained.ISS child
w/open epiphyses,6 mo
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
childhood-onset
(GH not rec in
adults who had
GH tx as child
for uses not due
to GH DF) AND
negative
response to 1
GH stim test
(insulin
tolerance [peak
less than 5
mcg/L], or
glucagon [peak
less than 3
mcg/L]) [GHRH
plus arginine
may be used if
available]
(exclude stim
test for
childhood-onset
due to
mutations,
lesions,
congenital
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
renal, heart,
liver, or BMT,
Crohn's disease,
cystic fibrosis,
dilated
cardiomyopathy
/heart failure,
end-stage renal
disease in adults
undergoing
hemodialysis,
Down's
syndrome,
familial
dysautonomia,
fibromyalgia,
HIV-infected
patients with
alterations in
body fat
distribution,
infertility,
kidney
transplant
patients
(children) with a
REQUIRED
MEDICAL
INFORMATION
trial if baseline Ht less
than 3rd pct (greater than
2 SD below mean for
gender/age) AND pretx
GR child less than 3 yrs
of less than 7 cm/yr and
child greater than or
equal to 3 yrs of less
than 4 cm/yr OR child
any age GR less than the
10th pct for age/gender
based on min 6 mos of
data AND PE certifies
child's basic activities of
daily living limited by
SS and has condition
which GH is/may be
effective AND PE
certifies via bone-age x-
ray, predicted adult Ht
less than 3rd pct.Auth
after initial tx (auth for
12 mos) based on
adequate clinical
response (annualized GR
doubles).Cont tx (after
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
defects),
transition adoles
off somatropin 1
mo before
retesting, OR 3
or more
pituitary
hormone
deficiencies
(TSH, ACTH,
LH/FSH, or
AVP) AND
serum IGF-1 84
microg/L or less
using the
Esoterix ECB
RIA or
age/gender
adjusted serum
IGF-1 SDS
below the 2.5
percentile.TS
start, female and
has short stature
(SS).SHOX
start, open
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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205

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
functional renal 12 to 18 mos), GR
allograft, liver increased by 2.5 cm/yr
transplantation, or more in MRY per MD
multiple system AND epiphyses open
atrophy, (older than 12
myelomeningoc yrs).Greater than 18 yrs,
ele, obesity, auth not allowed if
osteogenesis midparental ht attained.
imperfecta,
osteoporosis
(postmenopausa
l, idiopathic in
men,
glucocorticoidinduced),
thalassemia, and
X-linked
hypophosphate
mic rickets
(familial
hypophosphate
mia,
hypophosphate
mic rickets).
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
epiphyses.CRI
w/growth failure
(GF), start,
approve.Child
PW w/GF or
adult PW,
approve.NS
start, baseline ht
less than 3rd
percentile.TS/S
HOX/CRI/child
PW/NS, cont tx,
GR increased by
2.5 cm/yr or
more in most
recent yr (MRY)
AND epiphyses
open.SGA/IUG
R start, born
SGA AND no
sufficient catchup
growth
before age 4 yr,
AND age 2 to 8
yrs, if older than
8 yrs, approve 1
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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206

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
yr trial if
prepubertal,
AND baseline ht
less than 3rd
percentile for
gender/age.Cont
tx, GR increased
by 2.5 cm/yr or
more in most
recent, if aged 2
to 8 yrs, or by 3
or more cm/yr if
older than 8 yrs
and
prepubertal.HIV
w/wasting or
cachexia, HIVpositive
AND
have 1 of the
following,
documented
unintentional wt
loss of greater
than or equal to
10% from
baseline OR wt
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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207

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
less than 90% of
the lower limit
of ideal body wt
OR BMI less
than or equal to
20 kg/m2 AND
able to consume
or be fed via
parenteral or
enteral feedings
75% or more of
maintenance
energy
requirements
based on current
body weight
AND on
antiretroviral tx
greater than or
equal to 30 days
prior to
beginning GH tx
and will
continue
antiretroviral tx
throughout GH
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
txment. Repeat
12 or 24-wk
courses of GH
may be
authorized after
initial 12 or 24-
wk GH course
for HIV
infection
w/wasting or
cachexia
provided that
they are off GH
for at least 1 mo
and meet all of
previous HIV
criteria.HIVassoc
failure to
thrive.Able to
consume or be
fed via
parenteral or
enteral feedings
75% or more of
maintenance
energy
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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209

FORMULARY
DRUG
BRAND NAME
generic name
THIOTEPA INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
210
OTHER
CRITERIA
requirements
based on current
body wt AND
on antiretroviral
tx for greater
than or equal to
30 days prior to
beginning GH tx
and will
continue
antiretroviral
tx.SBS,
receiving
specialized
nutritional
support.SBS pts
eval on case-bycase
basis for
more than one
4-wk course per
yr.
This drug may
be covered
under
Medicare Part
B or D N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
TOBI NEB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
211
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
topiramate
sprinkle cap 1
topiramate tab 1
toposar inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
determination.
All FDAapproved
Authorization
indications not
will be for 12
otherwise
months, unless
excluded from
otherwise
Part D. N/A N/A N/A N/A
specified. N/A
All FDAapproved
Authorization
indications not
will be for 12
otherwise
months, unless
excluded from
otherwise
Part D. N/A N/A N/A N/A
specified. N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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212
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
topotecan inj. 1
TORISEL
SOLN 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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213
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
TRACLEER
TAB 2
DRUG
TIER
LEVEL
COVERED
USES
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D.
Patients
currently on
Letairis or
Tracleer for
treatment of
pulmonary
arterial
hypertension. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
For the FDA-approved
indication of pulmonary
arterial hypertension,
patients not currently on
Letairis or Tracleer are
required to have had a
right-heart
catheterization to
confirm the diagnosis of
PAH to ensure
appropriate medical
assessment. For the
FDA-approved
indication of pulmonary
arterial hypertension,
patients currently on
Letairis or Tracleer may N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
For treatment of
pulmonary arterial
hypertension,
Letairis or Tracleer
must be prescribed
by or in
consultation with a
cardiologist or a
pulmonologist.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
214
OTHER
CRITERIA
Digital ulcers,
approve
Tracleer if the
patient has tried
two other
therapies for this
condition such
as calcium
channel blockers
(eg, amlodipine,
felodipine,
isradipine,
nifedipine),
alpha-adrenergic
blockers (eg,
prazosin),
nitroglycerin,

FORMULARY
DRUG
BRAND NAME
generic name
TRAVASOL
INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
continue therapy if they
have a diagnosis of
PAH.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
215
OTHER
CRITERIA
phosphodiestera
se-5 inhibitors
(eg, sildenafil,
vardenafil), or
angiotensinconverting
enzyme
inhibitors (ACE
inhibitors), or
the patient has
tried one
vasodilator
product (eg,
intravenous
epoprostenol,
intravenous
alprostadil).

FORMULARY
DRUG
BRAND NAME
generic name
TREANDA INJ 2
tretinoin cream 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not N/A N/A N/A N/A
Authorization
will be for 12
months, unless
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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216
OTHER
CRITERIA
For topical
tretinoin
products

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
otherwise
excluded from
Part D.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
otherwise noted. (examples
include Atralin,
Avita, Retin-A,
Retin-A Micro,
Tretin-X, and
generic topical
tretinoin),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
sebaceous
hyperplasia/cyst,
basal cell
carcinoma [skin
cancer],
confluent and
reticulated
papillomatosis)
can be made if
the patient has
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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217

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
tried at least 1
other therapy.
For topical
adapalene
products
(examples
include Differin
gel, Differin
cream, etc. and
generic
adapalene
products),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
sebaceous
hyperplasia/cyst,
basal cell
carcinoma [skin
cancer],
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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218

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
confluent and
reticulated
papillomatosis,
Darier's disease,
molluscum
contagiosum)
can be made if
the patient has
tried at least 1
other therapy.
Coverage of the
combination
clindamycin
plus tretinoin
product (Ziana)
and the
combination
adapalene plus
benzoyl
peroxide
product
(Epiduo) is
recommended
for acne vulgaris
ONLY and all
other indications
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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219

FORMULARY
DRUG
BRAND NAME
generic name
tretinoin gel 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
220
OTHER
CRITERIA
are not
recommended.
For topical
tretinoin
products
(examples
include Atralin,
Avita, Retin-A,
Retin-A Micro,
Tretin-X, and
generic topical
tretinoin),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
sebaceous
Authorization hyperplasia/cyst,
will be for 12 basal cell
months, unless carcinoma [skin
otherwise noted. cancer],

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
confluent and
reticulated
papillomatosis)
can be made if
the patient has
tried at least 1
other therapy.
For topical
adapalene
products
(examples
include Differin
gel, Differin
cream, etc. and
generic
adapalene
products),
approval for the
treatment of
other noncosmetic
conditions (eg,
dermatitis/ecze
ma, folliculitis,
milia, keratosis
pilaris,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
sebaceous
hyperplasia/cyst,
basal cell
carcinoma [skin
cancer],
confluent and
reticulated
papillomatosis,
Darier's disease,
molluscum
contagiosum)
can be made if
the patient has
tried at least 1
other therapy.
Coverage of the
combination
clindamycin
plus tretinoin
product (Ziana)
and the
combination
adapalene plus
benzoyl
peroxide
product
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
222

FORMULARY
DRUG
BRAND NAME
generic name
TRISENOX
INJ. 2
TROPHAMINE
INJ 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
223
OTHER
CRITERIA
(Epiduo) is
recommended
for acne vulgaris
ONLY and all
other indications
are not
recommended.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under N/A N/A N/A N/A N/A N/A

FORMULARY
DRUG
BRAND NAME
generic name
TYKERB TAB 2
TYSABRI INJ 2
DRUG
TIER
LEVEL
COVERED
USES
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All medicallyaccepted
indications not
otherwise
excluded from
Part D. N/A
All FDA
approved
indications not
otherwise N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Diagnosis for which
Tykerb is being used.
For indication of breast
cancer, the HER2 status
must be reported. New
patients with breast
cancer which is HER2-
positive may receive
authorization for Tykerb. N/A
Adults with MS. Patient
has a relapsing form of
MS. Adults with CD.
Patient has moderately Adults
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
N/A
MS. Prescribed by
a neurologist or an
MS specialist
registered with the
COVERAGE
DURATION
Authorization
will be for 12
months.
Authorization
will be for 12
months, unless
otherwise
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
224
OTHER
CRITERIA
For breast
cancer, new
patient must
have HER2-
positive breast
cancer for
approval of
Tykerb.
Adults with MS.
Patient has a
relapsing form
of MS and has

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
excluded from
Part D.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
to severely active CD
with evidence of
inflammation (eg,
elevated C-reactive
protein).
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
TOUCH
prescribing
program. CD.
Prescribed by a
physician
registered with the
TOUCH program.
COVERAGE
DURATION
specified.
OTHER
CRITERIA
had an
inadequate
response to, or
is unable to
tolerate, therapy
with at least two
of the following
MS
medications:
interferon beta-
1a (Avonex,
Rebif),
interferon beta-
1b (Betaseron,
Extavia),
glatiramer
acetate
(Copaxone), or
fingolimod
(Gilenya).
Exceptions to
having tried an
interferon beta-
1a or -1b
product
(Avonex,
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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225

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
Betaseron,
Extavia, or
Rebif) can be
made if the
patient has
depression or a
mood disorder.
In these cases,
the patient
should try
glatiramer
acetate
(Copaxone) or
fingolimod
(Gilenya), but is
not required to
try an interferon
beta-1a or -1b.
Adults with CD.
Patient has
moderately to
severely active
CD with
evidence of
inflammation
(eg, elevated C-
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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226

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
reactive protein)
and has had an
inadequate
response to
treatment with
corticosteroids
(systemic),
azathioprine, 6-
mercaptopurine,
or methotrexate,
and patient has
tried two TNF
antagonists for
CD for at least 2
months each,
adalimumab,
certolizumab
pegol, or
infliximab, and
had an
inadequate
response or was
intolerant to the
TNF
antagonists.
Exception to the
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
227

FORMULARY
DRUG
BRAND NAME
generic name
TYZEKA TAB 2
UVADEX
SOLN 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Requires failure of
Hepsera, Baraclude or
Viread. N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
N/A
This drug may
be covered
under N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
228
OTHER
CRITERIA
CD criteria of
treatment with
corticosteroids
(systemic) are
allowed if
steroids are
contraindicated
or not desired,
then
azathioprine, 6-
mercaptopurine,
or methotrexate
must be tried if
they are not
contraindicated.

FORMULARY
DRUG
BRAND NAME
generic name
vancomycin inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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229
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
VECTIBIX INJ 2
VENTAVIS
SOLN. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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230
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
VFEND SUSP. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D worded
as invasive
aspergillosis,
esophageal
candidiasis,
treatment of
fungal
infections
caused by
Scedosporium
apiospermum
and Fusarium N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Esophageal candidasis
requires a trial of one
other systemic agent
(eg., fluconazole, IV
amphotericin B,
itraconazole). N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
231
OTHER
CRITERIA
For safety
reasons, if there
is insufficient
information
available to
make a
determination
regarding
coverage and
the prescribing
physician or
representative of
the physician
cannot be
contacted, then
approve 14-day
course.

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
spp., and
treatment of
candidemia in
nonneutropeni
c patients and
the following
Candida
infections:
disseminated
infections in
skin and
infections in
the abdomen,
kidney,
bladder wall,
and wounds,
treatment/prev
ention of other
serious
systemic or
suspected
systemic
fungal
infections.
Continuation
therapy for
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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232

FORMULARY
DRUG
BRAND NAME
generic name
VICTOZA INJ. 2
VICTRELIS
CAP 2
DRUG
TIER
LEVEL
COVERED
USES
patients
started/stabiliz
ed on
intravenous
(IV) or oral
voriconazole
for a systemic
infection.
All FDAapproved
indications not
otherwise
excluded from
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Part D. N/A N/A N/A N/A
All FDAapprovenanve
HCV RNA titers.Tx-
pts with chronic
indications not
HCV-1 monoinfection
otherwise
without cirrhosis and
excluded from
retx of pts with chronic
Part D. Plus
HCV-1 monoinfection
adult patients
who have been
with Hepatitis
previously treated with
B virus
interferon/peginterferon
(HBV)/chroni
alfa without
c HCV
cirrhosis,greater or equal
genotype 1 co-N/A
to 1 log10 reduction in Adults
PRESCRIBER
RESTRICTION
All FDA-approved
indications.
Prescribed by or in
consultation with a
gastroenterologist
or infectious
disease physician.
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
FDA-approved
indications,auth
orization=8wks
withTW 12, 24
assessment.Othr
=12mo.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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233
OTHER
CRITERIA
N/A
HCV RNA titers
not available but
sent approve
until available.
For all FDAapproved
indications,
patient must
have completed
or will be
completing a 4-
week lead-in

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
infection. HCV RNA at TW 4
required,TW 12 if HCV
RNA less than 100=addl
12wks if HCV RNA
greater or equal to
100=no addl,TW 24 if
early responder with
undetectable HCV RNA
and pt non-black and for
tx-naive pt with chronic
HCV-1 monoinfection
without cirrhosis=addl
4wks,TW 24 if early
responder with
undetectable HCV RNA
and pt non-black and for
retx in pt with chronic
HCV-1 monoinfection
previously treated for
HCV with
interferon/peginterferon
alfa without
cirrhosis=addl
12wks,TW 24 if early
responder with
undetectable HCV RNA
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
with
peginterferon
alfa and
ribavirin prior to
initiating
boceprevir and
boceprevir must
be prescribed in
combination as
triple-drug
therapy with
peginterferon
alfa and
ribavirin.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
234

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
and pt black=addl
24wks,TW 24 if late
responder with
undetectable HCV RNA
and pt non-black=addl
12wks if pt black=addl
24wks,TW 24 if early or
late responder with
detectable HCV
RNA=no addl. Retx in
pts with chronic HCV-1
monoinfection
previously treated with
interferon/peginterferon
alfa without cirrhosis
null-responder
documentation
required,TW 12 if HCV
RNA less than 100=addl
12wks if HCV RNA
greater or equal to
100=no addl,TW 24 if
HCV RNA
undetectable=addl
24wks if HCV RNA
detectable=no addl. Poor
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
235

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
interferon response with
chronic HCV-1
monoinfection and less
than 1 log10 reduction
HCV RNA after TW 4
without cirrhosis,TW 12
if HCV RNA less than
100=addl 12wks if HCV
RNA greater or equal to
100=no addl,TW 24 if
HCV RNA
undetectable=addl
24wks if HCV RNA
detectable=no addl.
Chronic HCV-1
monoinfection and
advanced
fibrosis/compensated
cirrhosis,TW 12 if HCV
RNA less than 100=addl
12 wks if HCV RNA
greater or equal to
100=no addl,TW 24 if
HCV RNA
undetectable=addl
24wks if HCV RNA
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
236

FORMULARY
DRUG
BRAND NAME
generic name
VIMPAT SOLN. 2
VIMPAT TAB 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
detectable=no addl.
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D.
Diabetic
neuropathic
pain. Seizure
disorders. N/A N/A N/A N/A
All FDAapproved
N/A N/A N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months.
Authorization
will be for 12
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
237
OTHER
CRITERIA
Diabetic
neuropathic pain
(DPN), approve
if the patient has
tried at least two
other therapies
for DPN -
tricyclic
antidepressants
(eg,
nortriptyline),
serotonin and
norepinephrine
reuptake
inhibitors
(SNRIs) (eg,
Cymbalta,
venlafaxine
extended-release
[Effexor XR]),
gabapentin,
Lyrica, or
Lidoderm.
Diabetic
neuropathic pain

FORMULARY
DRUG
BRAND NAME
generic name
VINBLASTINE
SULFATE INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
indications not
otherwise
excluded from
Part D.
Diabetic
neuropathic
pain. Seizure
disorders.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
months.
This drug may
be covered
under
Medicare Part
B or D N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
238
OTHER
CRITERIA
(DPN), approve
if the patient has
tried at least two
other therapies
for DPN -
tricyclic
antidepressants
(eg,
nortriptyline),
serotonin and
norepinephrine
reuptake
inhibitors
(SNRIs) (eg,
Cymbalta,
venlafaxine
extended-release
[Effexor XR]),
gabapentin,
Lyrica, or
Lidoderm.

FORMULARY
DRUG
BRAND NAME
generic name
vincasar pfs inj. 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
239
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
vincristine inj. 1
vinorelbine inj 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
240
OTHER
CRITERIA

FORMULARY
DRUG
BRAND NAME
generic name
voriconazole tab 1
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
All FDAapproved
indications not
otherwise
excluded from
Part D worded
as invasive
aspergillosis,
esophageal
candidiasis,
treatment of
fungal
infections
caused by
Scedosporium
apiospermum
and Fusarium
spp., and
treatment of N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Esophageal candidasis
requires a trial of one
other systemic agent
(eg., fluconazole, IV
amphotericin B,
itraconazole). N/A N/A
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
241
OTHER
CRITERIA
For safety
reasons, if there
is insufficient
information
available to
make a
determination
regarding
coverage and
the prescribing
physician or
representative of
the physician
cannot be
contacted, then
approve 14-day
course.

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
candidemia in
nonneutropeni
c patients and
the following
Candida
infections:
disseminated
infections in
skin and
infections in
the abdomen,
kidney,
bladder wall,
and wounds,
treatment/prev
ention of other
serious
systemic or
suspected
systemic
fungal
infections.
Continuation
therapy for
patients
started/stabiliz
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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242

FORMULARY
DRUG
BRAND NAME
generic name
VOTRIENT
TAB 2
XENAZINE
TAB 2
DRUG
TIER
LEVEL
COVERED
USES
ed on
intravenous
(IV) or oral
voriconazole
for a systemic
infection.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D.
Tardive
dyskinesia
(TD). Tourette
syndrome and
related tic
disorders.
Primary N/A N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Requires the
prescriber to be an
Oncologist or be in
under the direct
consultation with
an Oncologist.
For treatment of
chorea associated
with Huntington's
disease, Tourette
syndrome or
related tic
disorders, primary
hyperkinetic
dystonia, or
hemiballism,
Xenazine must be
prescribed by or
after consultation
COVERAGE
DURATION
Approved for
duration of plan
year subject to
formulary
change and
member
eligibility.
Authorization
will be for 12
months, unless
otherwise
specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
243
OTHER
CRITERIA
N/A
N/A

FORMULARY
DRUG
BRAND NAME
generic name
XEOMIN INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
hyperkinetic
dystonia.
Hemiballism.
All FDAapproved
indications not
otherwise
excluded from
Part D. Plus
Achalasia.
Anal Fissure.
BPH. Chronic
facial
pain/pain
associated
with TMJ
dysfunction.
Chronic low
back pain.
Headache
(migraine,
chronic
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Use in the
management of
cosmetic uses
(eg, facial
rhytides, frown
lines, glabellar
wrinkling,
horizontal neck
rhytides, mid
and lower face
and neck
rejuvenation,
platsymal bands,
rejuvenation of
the peri-orbital
region), allergic
rhinitis, gait
freezing in
Parkinsons N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
with a neurologist.
For TD, Xenazine
must be prescribed
by or after
consultation with a
neurologist or
psychiatrist.
COVERAGE
DURATION
Tinnitus if
prescribed by ENT.
Headache if Authorization
prescribed by, or will be for 12
after consultation months, unless
with, a neurologist otherwise
or HA specialist. specified.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
244
OTHER
CRITERIA
Primary axillary
hyperhydrosis
after trial with at
least 1 topical
agent (eg,
aluminum
chloride). BPH
after trial with at
least 2 other
therapies (eg,
alpha1-blocker,
5 alphareductase
inhibitor,
TURP,
transurethral
microwave heat
treatment,
TUNA,

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
tension HA,
whiplash,
chronic daily
HA).
Palmar/plantar
and facial
hyperhidrosis.
Myofascial
pain. Salivary
hypersecretion
. Spasticity
(eg, due to
cerebral palsy,
stroke, brain
injury, spinal
cord injury,
MS,
hemifacial
spasm).
Essential
tremor.
Dystonia other
than cervical
(eg, focal
dystonias,
tardive
EXCLUSION
CRITERIA
disease,
vaginismus,
interstitial
cystitis, or
Crocodile tears
syndrome.
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
interstitial laser
therapy, stents,
various forms of
surgery).
Chronic low
back pain after
trial with at least
2 other
pharmacologic
therapies (eg,
NSAID,
antispasmodics,
muscle
relaxants,
opioids,
antidepressants)
and if being
used as part of a
multimodal
therapeutic pain
management
program.
Tinnitus after a
trial with at least
2 other
pharmacologic
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
245

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
dystonia,
anismus).
Bladder/voidin
g/urethral
dysfunction.
Frey's
syndrome
(gustatory
sweating).
Ophthalmic
disorders (eg,
esotropia,
exotropia,
nystagmus,
facial nerve
paresis).
Speech/voice
disorders (eg,
dysphonias).
Tourette's
syndrome.
Additional
indications
will be
evaluated by a
pharmacist
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
therapies (eg,
lidocaine,
antihistamines,
antidepressants,
anxiolytics,
diuretics,
anticonvulsants,
antispastics) and
tinnitus
retraining
therapy.
Headache (eg,
migraine,
chronic tension
headache,
whiplash,
chronic daily
headache) after
a trial with at
least 2 other
pharmacologic
therapies (eg,
anticonvulsants,
antidepressants,
beta-blockers,
calcium channel
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
246

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
and/or a
physician on a
case-by-case
basis.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
blockers, nonsteroidal
antiinflammatory
drugs).
Palmar/plantar
and facial
hyperhidrosis
after a trial with
at least 1 topical
agent (eg,
aluminum
chloride).
Essential tremor
after a trial with
at least 1 other
pharmacologic
therapy (eg,
primidone,
propranolol,
benzodiazepines
, gabapentin,
topiramate).
Bladder/Voiding
/Urethral
dysfunction
after a trial with
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
247

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
at least 1 other
pharmacologic
therapy (eg, oral
antimuscarinic
agents).
Gastroparesis
after a trial with
at least 1
promotility drug
(eg,
metoclopramide,
tegasterod,
erythromycin).
Tourette's
syndrome if
after a trial with
at least 1 more
commonly used
pharmacologic
therapy (eg,
neuroleptics,
clonidine,
SSRIs,
psychostimulant
s).
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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248

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
XOLAIR INJ. 2 All FDAapproved
indications not
otherwise
excluded from
Part D
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
N/A
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
Moderate to severe Patients aged 12
persistent asthma, years and older.
baseline IgE level of at
least 30 IU/mL. For
asthma, patient has a
positive skin test or in
vitro testing (ie, a blood
test for allergen-specific
IgE antibodies such as
the RAST) for 1 or more
perennial aeroallergens
(eg, house dust mite,
animal dander [dog, cat],
cockroach, feathers,
mold spores) and/or for
1 or more seasonal
aeroallergens (grass,
pollen, weeds).
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Moderate to severe Authorization
persistent asthma if will be for 12
prescribed by, or in months, unless
consultation with otherwise
an allergist, specified.
immunologist, or
pulmonologist.
SAR/PAR if
prescribed by an
allergist,
immunologist, or
pulmonologist.
EG/EE/EC, if
prescribed by or in
consultation with
an allergist,
immunologist, or
gastroenterologist.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
249
OTHER
CRITERIA
Moderate to
severe persistent
asthma must
meet all criteria.
Patient's asthma
symptoms have
not been
adequately
controlled by
concomitant use
of at least 2
months of
inhaled
corticosteroid
and a longacting
betaagonist
(LABA)
or LABA
alternative, if
LABA
contraindicated
or pt has
intolerance then
alternatives
include
sustained-

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
release
theophylline or
a leukotriene
modifier (eg,
montelukast),
AND inadequate
control
demonstrated by
hospitalization
for asthma,
requirement for
systemic
corticosteroids
to control
asthma
exacerbation(s),
or increasing
need (eg, more
than 4 times a
day) for shortacting
inhaled
beta2 agonists
for symptoms
(excluding
preventative use
for exercise-
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
250

FORMULARY
DRUG
BRAND NAME
generic name
XOPENEX
NEB 2
XTANDI CAP 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination. N/A N/A N/A N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
Prescribed by or in
consult with
Oncology
Specialist
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
251
OTHER
CRITERIA
induced
asthma).
N/A

FORMULARY
DRUG
BRAND NAME
generic name
ZALTRAP INJ. 2
ZANOSAR INJ 2
ZEMPLAR CAP 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
formulary
change and
member
eligibility.
determination. N/A N/A N/A N/A N/A N/A
This drug may
be covered N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
252
OTHER
CRITERIA
N/A

FORMULARY
DRUG
BRAND NAME
generic name
ZEMPLAR INJ. 2
DRUG
TIER
LEVEL
COVERED
USES
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the
determination.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
253
OTHER
CRITERIA

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
use and setting
of the drug to
make the
determination.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
zonisamide cap 1
ZORTRESS
TAB 2
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A N/A
Authorization
will be for 12
months, unless
otherwise
specified.
N/A
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted
describing the
use and setting
of the drug to
make the N/A N/A N/A N/A N/A N/A
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
254

CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
FORMULARY
DRUG
BRAND NAME
generic name
ZYTIGA TAB 2
ZYVOX SUSP. 2
ZYVOX TAB 2
DRUG
TIER
LEVEL
COVERED
USES
determination.
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
All FDAapproved
indications not
otherwise
excluded from
Part D. N/A N/A N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
Approved for
duration of
contract year
subject to
Prescribed by or in formulary
consult with
Oncology
Specialist
change and
member
eligibility. N/A
Infectious Disease
Specialist or in
consultation with
an Infectious
Disease Specialist
concerning the
patient. 3 months N/A
Infectious Disease
Specialist or in
consultation with
an Infectious
Disease Specialist
concerning the
patient. 3 months N/A
OTHER
CRITERIA
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
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255