2013 Prior Authorization Drug Requirements - CCHP
2013 Prior Authorization Drug Requirements - CCHP
2013 Prior Authorization Drug Requirements - CCHP
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FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ABRAXANE<br />
SUSP 1<br />
acetylcysteine<br />
soln. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
1<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ACTEMRA INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Systemiconset<br />
juvenile<br />
idiopathic<br />
arthritis (JIA).<br />
Plus patients<br />
already started<br />
on tocilizumab<br />
for a Covered<br />
Use. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
For indication of<br />
systemic-onset<br />
JIA, may approve<br />
for children and<br />
adolescents 18<br />
years of age or<br />
younger. For<br />
rheumatoid<br />
arthritis (RA) and<br />
Still's disease,<br />
approve for adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
Adults with RA,<br />
tocilizumab is to be<br />
prescribed by a<br />
rheumatologist or<br />
in consultation<br />
with a<br />
rheumatologist.<br />
Systemic-onset<br />
JIA, tocilizumab is<br />
to be prescribed by<br />
a rheumatologist.<br />
Castleman's<br />
disease, approve if<br />
patient is under the<br />
care of an<br />
oncologist or<br />
hematologist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
2<br />
OTHER<br />
CRITERIA<br />
Adults with RA,<br />
approve for<br />
patients who<br />
have tried for at<br />
least 2 months<br />
or who were<br />
intolerant to one<br />
of the following<br />
TNF antagonists<br />
, adalimumab,<br />
certolizumab<br />
pegol,<br />
etanercept,<br />
golimumab, or<br />
infliximab.<br />
Systemic-onset<br />
JIA, approve for<br />
patients who<br />
have tried a<br />
systemic
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ADAGEN INJ. 2<br />
adapalene cream 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
3<br />
OTHER<br />
CRITERIA<br />
corticosteroid,<br />
and either MTX<br />
or sulfasalazine<br />
or another<br />
DMARD such<br />
as etanercept.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise N/A N/A N/A N/A<br />
<strong>Authorization</strong> For topical<br />
will be for 12 tretinoin<br />
months, unless products<br />
otherwise noted. (examples
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
excluded from<br />
Part D.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
include Atralin,<br />
Avita, Retin-A,<br />
Retin-A Micro,<br />
Tretin-X, and<br />
generic topical<br />
tretinoin),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
sebaceous<br />
hyperplasia/cyst,<br />
basal cell<br />
carcinoma [skin<br />
cancer],<br />
confluent and<br />
reticulated<br />
papillomatosis)<br />
can be made if<br />
the patient has<br />
tried at least 1<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
4
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
other therapy.<br />
For topical<br />
adapalene<br />
products<br />
(examples<br />
include Differin<br />
gel, Differin<br />
cream, etc. and<br />
generic<br />
adapalene<br />
products),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
sebaceous<br />
hyperplasia/cyst,<br />
basal cell<br />
carcinoma [skin<br />
cancer],<br />
confluent and<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
5
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
reticulated<br />
papillomatosis,<br />
Darier's disease,<br />
molluscum<br />
contagiosum)<br />
can be made if<br />
the patient has<br />
tried at least 1<br />
other therapy.<br />
Coverage of the<br />
combination<br />
clindamycin<br />
plus tretinoin<br />
product (Ziana)<br />
and the<br />
combination<br />
adapalene plus<br />
benzoyl<br />
peroxide<br />
product<br />
(Epiduo) is<br />
recommended<br />
for acne vulgaris<br />
ONLY and all<br />
other indications<br />
are not<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
6
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
adapalene gel 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
7<br />
OTHER<br />
CRITERIA<br />
recommended.<br />
For topical<br />
tretinoin<br />
products<br />
(examples<br />
include Atralin,<br />
Avita, Retin-A,<br />
Retin-A Micro,<br />
Tretin-X, and<br />
generic topical<br />
tretinoin),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
sebaceous<br />
hyperplasia/cyst,<br />
<strong>Authorization</strong> basal cell<br />
will be for 12 carcinoma [skin<br />
months, unless cancer],<br />
otherwise noted. confluent and
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
reticulated<br />
papillomatosis)<br />
can be made if<br />
the patient has<br />
tried at least 1<br />
other therapy.<br />
For topical<br />
adapalene<br />
products<br />
(examples<br />
include Differin<br />
gel, Differin<br />
cream, etc. and<br />
generic<br />
adapalene<br />
products),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
sebaceous<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
8
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
hyperplasia/cyst,<br />
basal cell<br />
carcinoma [skin<br />
cancer],<br />
confluent and<br />
reticulated<br />
papillomatosis,<br />
Darier's disease,<br />
molluscum<br />
contagiosum)<br />
can be made if<br />
the patient has<br />
tried at least 1<br />
other therapy.<br />
Coverage of the<br />
combination<br />
clindamycin<br />
plus tretinoin<br />
product (Ziana)<br />
and the<br />
combination<br />
adapalene plus<br />
benzoyl<br />
peroxide<br />
product<br />
(Epiduo) is<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
9
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ADCIRCA TAB 2<br />
adriamycin inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For initial approval for<br />
use in pulmonary arterial<br />
hypertension (PAH),<br />
approve if patient has<br />
had a right-heart<br />
catheterization to<br />
confirm diagnosis of<br />
PAH to ensure<br />
appropriate medical<br />
assessment. For patients<br />
currently receiving<br />
sildenafil or tadalafil,<br />
approve if patient has a<br />
diagnosis of PAH.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
For PAH, if <strong>Authorization</strong><br />
prescribed by, or in will be for 12<br />
consultation with, a months, unless<br />
cardiologist or a otherwise<br />
pulmonologist. specified.<br />
Part D. N/A<br />
N/A<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
10<br />
OTHER<br />
CRITERIA<br />
recommended<br />
for acne vulgaris<br />
ONLY and all<br />
other indications<br />
are not<br />
recommended.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ADVAIR<br />
DISKUS 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
COPD.<br />
Chronic<br />
bronchitis.<br />
Emphysema.<br />
Postinfectious<br />
cough (ie,<br />
cough<br />
persisting after<br />
an acute<br />
respiratory N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
11<br />
OTHER<br />
CRITERIA<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ADVAIR HFA<br />
INHALER 2<br />
AFINITOR TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
infection has<br />
resolved).<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
COPD.<br />
Chronic<br />
bronchitis.<br />
Emphysema.<br />
Postinfectious<br />
cough (ie,<br />
cough<br />
persisting after<br />
an acute<br />
respiratory<br />
infection has<br />
resolved). N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
For the treatment of<br />
progressive<br />
neuroendocrine tumors<br />
of pancreatic origin in<br />
patients with<br />
unresectable, locally N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
12<br />
OTHER<br />
CRITERIA<br />
N/A<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
albuterol neb 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
advanced, or metastatic<br />
member<br />
disease. For the<br />
eligibility.<br />
treatment of patients<br />
with advanced renal cell<br />
carcinoma after failure<br />
of treatment with Sutent<br />
or Nexavar. For the<br />
treatment of patients<br />
with subependymal giant<br />
cell astrocytoma<br />
associated with tuberous<br />
sclerosis who require<br />
therapeutic intervention<br />
but are not candidates<br />
for curative surgical<br />
resection.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
13<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
amifostine inj. 1<br />
aminosyn inj. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
14<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
AMINOSYN II<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
15<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
AMINOSYN M<br />
INJ. 2<br />
AMINOSYN-<br />
HBC INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
16<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
AMINOSYN-PF<br />
INJ. 2<br />
AMPYRA TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
N/A N/A N/A<br />
MS. If prescribed<br />
by, or in<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
17<br />
OTHER<br />
CRITERIA<br />
Initial approval For initial<br />
for MS, 90 days. approval for
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
patient already<br />
started on<br />
dalfampridine<br />
extendedrelease<br />
for<br />
Multiple<br />
Sclerosis<br />
(MS).<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
consultation with,<br />
an MS specialist.<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
Subsequent MS, authorize<br />
authorization for for 90 days.<br />
12 mos if patient After up to 90<br />
had a response. days of<br />
dalfampridine<br />
extended-release<br />
therapy, if MS<br />
patient has had a<br />
response to<br />
therapy as<br />
determined by<br />
prescribing<br />
physician (eg,<br />
increased<br />
walking<br />
distance,<br />
improved<br />
leg/limb<br />
strength,<br />
improvement in<br />
activities of<br />
daily living),<br />
then an<br />
additional<br />
authorization is<br />
allowed.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
18
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ANDROGEL 2<br />
ARALAST NP<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Alpha-<br />
1 antitrypsin<br />
(AAT)<br />
deficiencyassociated<br />
panniculitis. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Two morning<br />
testosterone levels fall<br />
below the normal range<br />
for a healthy adult male. N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
19<br />
N/A<br />
For AAT deficiency<br />
with emphysema (or<br />
COPD), approve in<br />
patients with baseline<br />
(pretreatment) alpha1-<br />
antitrypsin serum<br />
concentration less than<br />
11 microM (11<br />
micromol/L) or 80<br />
mg/dL. N/A N/A<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
OTHER<br />
CRITERIA<br />
N/A<br />
For all covered<br />
uses, the patient<br />
is required to try<br />
Aralast NP first<br />
line. For AAT<br />
deficiency with<br />
emphysema (or<br />
COPD), approve<br />
in patients with<br />
baseline<br />
(pretreatment)<br />
alpha1-<br />
antitrypsin<br />
serum<br />
concentration<br />
less than 11<br />
microM (11<br />
micromol/L) or
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ARCALYST<br />
INJ. 2<br />
ARRANON INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
patient already<br />
started on<br />
rilonacept for<br />
Muckle Wells<br />
Syndrome<br />
(MWS) or<br />
Familial Cold<br />
Autoinflamma<br />
tory Syndrome<br />
(FCAS). N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Greater than or<br />
equal to 12 years<br />
of age.<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
20<br />
OTHER<br />
CRITERIA<br />
80 mg/dL.<br />
Patients already<br />
started on<br />
rilonacept for<br />
MWS/FCAS<br />
may receive<br />
authorization if<br />
Initial approval they have had a<br />
of MWS/FCAS, response and are<br />
2 mos. continuing<br />
Subsequent therapy to<br />
authorization for maintain<br />
12 mos if patient response/remissi<br />
had a response. on.<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ARZERRA 2<br />
ATGAM INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
21<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
AVONEX KIT 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Multiple<br />
Sclerosis N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Prescribed by or<br />
after consultation<br />
with a neurologist<br />
or an MS<br />
specialist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
22<br />
OTHER<br />
CRITERIA<br />
Approve for<br />
patients already<br />
started on<br />
Avonex. For<br />
patients not<br />
currently on<br />
Avonex,<br />
approve if the<br />
patient has<br />
previously tried<br />
Betaseron,<br />
Copaxone, or<br />
Rebif.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
AVONEX<br />
PREFILL KIT 2<br />
AXIRON SOLN 2<br />
azathioprine inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Multiple<br />
Sclerosis N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
AGE<br />
RESTRICTION<br />
Two morning<br />
testosterone levels fall<br />
below the normal range<br />
for a healthy adult male.<br />
Patient must have tried<br />
and failed<br />
ANDRODERM and<br />
ANDROGEL N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
Prescribed by or<br />
after consultation<br />
with a neurologist<br />
or an MS<br />
specialist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
23<br />
OTHER<br />
CRITERIA<br />
Approve for<br />
patients already<br />
started on<br />
Avonex. For<br />
patients not<br />
currently on<br />
Avonex,<br />
approve if the<br />
patient has<br />
previously tried<br />
Betaseron,<br />
Copaxone, or<br />
Rebif.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
azathioprine tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
24<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
BETASERON<br />
INJ. 2<br />
BICNU INJ. 2<br />
bleomycin sulfate<br />
inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
determination.<br />
All FDAapproved<br />
Prescribed by or <strong>Authorization</strong><br />
indications not<br />
after consultation will be for 12<br />
otherwise<br />
with a neurologist months, unless<br />
excluded from<br />
or an MS otherwise<br />
Part D. N/A N/A N/A<br />
specialist. specified. N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
25<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
BOSULIF<br />
TAB 2<br />
BOTOX INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
All FDAapproved<br />
management of<br />
Use in the<br />
indications not cosmetic uses<br />
otherwise (eg, facial<br />
excluded from rhytides, frown N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
<strong>Authorization</strong><br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
26<br />
N/A<br />
Tinnitus if<br />
prescribed by ENT. will be for 12<br />
Headache if months, unless<br />
prescribed by, or otherwise<br />
after consultation specified.<br />
OTHER<br />
CRITERIA<br />
N/A<br />
Primary axillary<br />
hyperhydrosis<br />
after trial with at<br />
least 1 topical<br />
agent (eg,
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Part D. Plus<br />
Achalasia.<br />
Anal Fissure.<br />
BPH. Chronic<br />
facial<br />
pain/pain<br />
associated<br />
with TMJ<br />
dysfunction.<br />
Chronic low<br />
back pain.<br />
Headache<br />
(migraine,<br />
chronic<br />
tension HA,<br />
whiplash,<br />
chronic daily<br />
HA).<br />
Palmar/plantar<br />
and facial<br />
hyperhidrosis.<br />
Myofascial<br />
pain. Salivary<br />
hypersecretion<br />
. Spasticity<br />
(eg, due to<br />
EXCLUSION<br />
CRITERIA<br />
lines, glabellar<br />
wrinkling,<br />
horizontal neck<br />
rhytides, mid<br />
and lower face<br />
and neck<br />
rejuvenation,<br />
platsymal bands,<br />
rejuvenation of<br />
the peri-orbital<br />
region), allergic<br />
rhinitis, gait<br />
freezing in<br />
Parkinsons<br />
disease,<br />
vaginismus,<br />
interstitial<br />
cystitis, or<br />
Crocodile tears<br />
syndrome.<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
with, a neurologist<br />
or HA specialist.<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
aluminum<br />
chloride). BPH<br />
after trial with at<br />
least 2 other<br />
therapies (eg,<br />
alpha1-blocker,<br />
5 alphareductase<br />
inhibitor,<br />
TURP,<br />
transurethral<br />
microwave heat<br />
treatment,<br />
TUNA,<br />
interstitial laser<br />
therapy, stents,<br />
various forms of<br />
surgery).<br />
Chronic low<br />
back pain after<br />
trial with at least<br />
2 other<br />
pharmacologic<br />
therapies (eg,<br />
NSAID,<br />
antispasmodics,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
27
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
cerebral palsy,<br />
stroke, brain<br />
injury, spinal<br />
cord injury,<br />
MS,<br />
hemifacial<br />
spasm).<br />
Essential<br />
tremor.<br />
Dystonia other<br />
than cervical<br />
(eg, focal<br />
dystonias,<br />
tardive<br />
dystonia,<br />
anismus).<br />
Bladder/voidin<br />
g/urethral<br />
dysfunction.<br />
Frey's<br />
syndrome<br />
(gustatory<br />
sweating).<br />
Ophthalmic<br />
disorders (eg,<br />
esotropia,<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
muscle<br />
relaxants,<br />
opioids,<br />
antidepressants)<br />
and if being<br />
used as part of a<br />
multimodal<br />
therapeutic pain<br />
management<br />
program.<br />
Tinnitus after a<br />
trial with at least<br />
2 other<br />
pharmacologic<br />
therapies (eg,<br />
lidocaine,<br />
antihistamines,<br />
antidepressants,<br />
anxiolytics,<br />
diuretics,<br />
anticonvulsants,<br />
antispastics) and<br />
tinnitus<br />
retraining<br />
therapy.<br />
Headache (eg,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
28
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
exotropia,<br />
nystagmus,<br />
facial nerve<br />
paresis).<br />
Speech/voice<br />
disorders (eg,<br />
dysphonias).<br />
Tourette's<br />
syndrome.<br />
Additional<br />
indications<br />
will be<br />
evaluated by a<br />
pharmacist<br />
and/or a<br />
physician on a<br />
case-by-case<br />
basis.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
migraine,<br />
chronic tension<br />
headache,<br />
whiplash,<br />
chronic daily<br />
headache) after<br />
a trial with at<br />
least 2 other<br />
pharmacologic<br />
therapies (eg,<br />
anticonvulsants,<br />
antidepressants,<br />
beta-blockers,<br />
calcium channel<br />
blockers, nonsteroidal<br />
antiinflammatory<br />
drugs).<br />
Palmar/plantar<br />
and facial<br />
hyperhidrosis<br />
after a trial with<br />
at least 1 topical<br />
agent (eg,<br />
aluminum<br />
chloride).<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
29
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
Essential tremor<br />
after a trial with<br />
at least 1 other<br />
pharmacologic<br />
therapy (eg,<br />
primidone,<br />
propranolol,<br />
benzodiazepines<br />
, gabapentin,<br />
topiramate).<br />
Bladder/Voiding<br />
/Urethral<br />
dysfunction<br />
after a trial with<br />
at least 1 other<br />
pharmacologic<br />
therapy (eg, oral<br />
antimuscarinic<br />
agents).<br />
Gastroparesis<br />
after a trial with<br />
at least 1<br />
promotility drug<br />
(eg,<br />
metoclopramide,<br />
tegasterod,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
30
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. All<br />
medically<br />
accepted<br />
indications not<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
Restricted to or in formulary<br />
BRILINTA<br />
otherwise<br />
excluded from<br />
consult with<br />
Cardiology<br />
change and<br />
member<br />
TAB 2 Part D N/A N/A N/A<br />
Specialist. eligibility. N/A<br />
budesonide susp. 1 This drug may N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
31<br />
OTHER<br />
CRITERIA<br />
erythromycin).<br />
Tourette's<br />
syndrome if<br />
after a trial with<br />
at least 1 more<br />
commonly used<br />
pharmacologic<br />
therapy (eg,<br />
neuroleptics,<br />
clonidine,<br />
SSRIs,<br />
psychostimulant<br />
s).
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
BUSULFEX<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
32<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
BYETTA INJ. 2<br />
calcitriol cap 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
33<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
calcitriol inj. 1<br />
calcitriol soln. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
34<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
CAPRELSA<br />
TAB 2<br />
carboplatin inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Prescribed by an<br />
Oncologist or<br />
Endocrinologist or<br />
under the direct<br />
consultation of an<br />
Oncologist or<br />
Endocrinologist.<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
35<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
CARIMUNE NF<br />
INJ. 2<br />
carisoprodol/<br />
aspirin tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from N/A<br />
N/A<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria N/A<br />
<strong>Authorization</strong><br />
will be for 1<br />
month.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
36<br />
OTHER<br />
CRITERIA<br />
Musculoskeletal<br />
conditions/disor<br />
ders, approve if<br />
the patient has<br />
tried two other
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
CAYSTON 28<br />
DAY 2<br />
CELLCEPT IV<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
37<br />
OTHER<br />
CRITERIA<br />
Part D. apply. therapies for the<br />
current<br />
condition.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
Restricted to or in<br />
consult with<br />
Infectious Disease<br />
or Pulmonology<br />
Specialist.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
Approval will<br />
be based off<br />
BvD coverage<br />
determination.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
CELLCEPT<br />
SUSP. 2<br />
CEREZYME<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
38<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
CERUBIDINE<br />
INJ 2<br />
CESAMET<br />
CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
39<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
chlorzoxazone<br />
tab 1<br />
chorionic<br />
gonadotropin inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from N/A<br />
N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
Prepubertal<br />
cryptorchidism,<br />
child or adolescent.<br />
Hypospadias or<br />
epispadias. N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 1<br />
month.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
noted otherwise.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
40<br />
OTHER<br />
CRITERIA<br />
Musculoskeletal<br />
conditions/disor<br />
ders, approve if<br />
the patient has<br />
tried two other<br />
therapies for the<br />
current<br />
condition.<br />
Hypogonadotro<br />
pic<br />
hypogonadism<br />
in males.<br />
Preoperative use
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ciclopirox nail<br />
lacquer 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Part D.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Allowed use only<br />
in patients 4 years<br />
and older.<br />
Onychomycosis must be<br />
confirmed by positive<br />
KOH, fungal culture,<br />
DTM culture, nail<br />
biopsy, or histologic<br />
examination (PAS) is<br />
required before therapy<br />
initiation. Before a<br />
second course of<br />
treatment is permitted<br />
for onychomycosis, a<br />
culture must demonstrate<br />
a fungal infection. Use<br />
of topical ciclopirox 8%<br />
solution with terbinafine,<br />
itraconazole, or<br />
fluconazole (for<br />
onychomycosis use) is<br />
not permitted. N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for up to<br />
48 weeks. N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
41<br />
OTHER<br />
CRITERIA<br />
for hypospadias<br />
and chordee OR<br />
total epispadias<br />
and bladder<br />
exstrophy in<br />
male infants or<br />
toddlers.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For moderate to severe<br />
RA requires intolerance<br />
to or failure of therapy<br />
with methotrexate<br />
(greater than 20mg/wk). N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
For RA must be<br />
prescribed by<br />
Rheumatology<br />
Specialist. For<br />
Crohn's Disease<br />
must be prescribed<br />
by<br />
Gastroenterology<br />
Specialist.<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
CIMZIA INJ 2<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
cisplatin inj 1 determination. N/A N/A N/A N/A N/A N/A<br />
CLINIMIX E 2 This drug may N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
42<br />
OTHER<br />
CRITERIA<br />
For members<br />
with a diagnosis<br />
of early, severeonset<br />
RA, or<br />
Crohn's Disease<br />
additional<br />
required medical<br />
information is<br />
not required.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
INJ.<br />
CLINIMIX INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
43<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
clinisol sf inj. 2<br />
colistimethate<br />
inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
44<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
COMETRIQ<br />
PACK 2<br />
COPAXONE<br />
KIT 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Multiple N/A<br />
Patients with a diagnosis<br />
of multiple sclerosis<br />
(MS) or have<br />
experienced an attack<br />
and who are at risk of<br />
MS<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
45<br />
N/A<br />
Prescribed by or<br />
after consultation<br />
with a neurologist<br />
or an MS<br />
specialist.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
OTHER<br />
CRITERIA<br />
N/A<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
cromolyn neb 1<br />
CUBICIN INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Sclerosis<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
46<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
cyclophosphamid<br />
e tab 1<br />
cyclosporine cap 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
47<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
cyclosporine inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
48<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
cyclosporine<br />
modified cap 1<br />
cyclosporine<br />
modified soln. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
49<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
cyproheptadine<br />
syrup 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
50<br />
OTHER<br />
CRITERIA<br />
Approve if the<br />
patient has tried<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,<br />
desloratadine,<br />
levocetirizine,<br />
fexofenadine/ps<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
condition.<br />
Approve<br />
promethazine<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
diphenhydramin<br />
e (capsules or<br />
elixir) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
51
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
cyproheptadine<br />
tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
52<br />
OTHER<br />
CRITERIA<br />
management of<br />
insomnia.<br />
Approve<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
Approve if the<br />
patient has tried<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
desloratadine,<br />
levocetirizine,<br />
fexofenadine/ps<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current<br />
condition.<br />
Approve<br />
promethazine<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
53
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
54<br />
OTHER<br />
CRITERIA<br />
diphenhydramin<br />
e (capsules or<br />
elixir) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
insomnia.<br />
Approve<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
cytarabine inj. 1 This drug may N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
dacarbazine inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
55<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DACOGEN<br />
INJ. 2<br />
daunorubicin inj 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
56<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
dexrazoxane inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
57<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
diphenhydramine<br />
cap 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
58<br />
OTHER<br />
CRITERIA<br />
Approve if the<br />
patient has tried<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,<br />
desloratadine,<br />
levocetirizine,<br />
fexofenadine/ps<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current<br />
condition.<br />
Approve<br />
promethazine<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
diphenhydramin<br />
e (capsules or<br />
elixir) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
insomnia.<br />
Approve<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
59
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
60<br />
OTHER<br />
CRITERIA<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
DOCETAXEL<br />
INJ. 2<br />
DOXIL INJ. 2 This drug may N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
doxorubicin inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
61<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
dronabinol cap 1<br />
ELITEK INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
62<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ELOXATIN<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
63<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ELSPAR INJ. 2<br />
EMEND CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
64<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
EMEND PACK 2<br />
ENBREL INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not N/A<br />
For moderate to severe<br />
RA, Psoriatic Arthritis or<br />
Reactive Arithritis N/A<br />
Rheumatoid<br />
Arthritis, Psoriatic<br />
Arthritis, Reactive<br />
Approved for<br />
duration of the<br />
contract year<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
65<br />
OTHER<br />
CRITERIA<br />
For members<br />
with a diagnosis<br />
of early, severe-
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
otherwise<br />
excluded from<br />
Part D.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
requires intolerance to or<br />
failure of therapy with<br />
methotrexate (greater<br />
than 20mg/wk). Plaque<br />
Psoriasis: Failure of<br />
methotrexate at a dose of<br />
15mg/week or failed<br />
soriatane.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Arthritis and<br />
Ankylosing<br />
Spondylitis:<br />
Prescriber must be<br />
a Rheumatologist.<br />
All Plaque<br />
Psoriasis:<br />
Prescriber must be<br />
a Dermatologist.<br />
COVERAGE<br />
DURATION<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
ENGERIX-B<br />
make the<br />
INJ. 2 determination. N/A N/A N/A N/A N/A N/A<br />
enoxaparin inj. 1 This drug may N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
66<br />
OTHER<br />
CRITERIA<br />
onset RA,<br />
additional<br />
required medical<br />
information is<br />
not required.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
EPOGEN INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D worded<br />
as anemia<br />
associated<br />
with chronic<br />
renal failure<br />
(CRF), N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
CRF<br />
anemia.Hemoglobin<br />
(Hb) of less than or<br />
equal to 10.0 g/dL to<br />
start.Hb less than or<br />
equal to 12.0 g/dL if<br />
previously on epoetin<br />
alfa (EA) or<br />
Aranesp.Anemia<br />
w/myelosuppressive<br />
chemotx.Hb<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
67<br />
N/A<br />
AA, prescribed by<br />
a hematologist.<br />
Preop approval:<br />
1 month. All<br />
others initial<br />
appr 3months.<br />
Reauth at 3<br />
month intervals<br />
OTHER<br />
CRITERIA<br />
Part B versus<br />
Part D<br />
determination<br />
will be made at<br />
time of prior<br />
authorization<br />
review per CMS<br />
guidance to<br />
establish if the<br />
drug prescribed<br />
is to be used for
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
including<br />
patients on<br />
dialysis and<br />
not on<br />
dialysis, and<br />
worded as<br />
anemia<br />
secondary to<br />
myelosuppress<br />
ive anticancer<br />
chemotherapy<br />
in solid<br />
tumors,<br />
multiple<br />
myeloma,<br />
lymphoma,<br />
and<br />
lymphocytic<br />
leukemia. Plus<br />
anemia in<br />
patients with<br />
HIV who are<br />
receiving<br />
zidovudine.<br />
Anemic<br />
patients (Hb of<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
immediately prior to EA<br />
is 10.0 g/dL or less (or<br />
hematocrit [Hct] is 30%<br />
or less).EA maintenance<br />
is starting dose if Hb<br />
level remains 10.0 g/dL<br />
or less (or Hct remains<br />
30% or less) 4 wks after<br />
start and Hb rise is 1.0<br />
g/dL or more (Hct rise is<br />
3% or more).Pts w/Hb<br />
rises less than 1.0 g/dL<br />
(Hct rise less than 3%)<br />
vs pretx baseline over 4<br />
wks of tx and Hb is less<br />
than 10.0 g/dL after 4<br />
wks of tx (Hct is less<br />
than 30%), the<br />
recommended FDA<br />
starting dose may be<br />
increased once by<br />
25%.Continued use is<br />
not reasonable/necessary<br />
if Hb rises less than 1.0<br />
g/dL (Hct rise less than<br />
3%) vs pretx baseline by<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
an end-stage<br />
renal disease<br />
(ESRD)-related<br />
condition.<br />
Anemia<br />
secondary to<br />
myelosuppressiv<br />
e anticancer<br />
chemotherapy in<br />
solid tumors,<br />
multiple<br />
myeloma,<br />
lymphoma, and<br />
lymphocytic<br />
leukemia. Pts<br />
with Hb rise of<br />
less than 1.0<br />
g/dL (or Hct 3%<br />
or less) and Hb<br />
levels is less<br />
than 10.0 g/dL<br />
after 4 wks<br />
therapy, the<br />
recommended<br />
FDA dose may<br />
be increased<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
68
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
13.0 g/dL or<br />
less) at high<br />
risk for<br />
perioperative<br />
transfusions<br />
(secondary to<br />
significant,<br />
anticipated<br />
blood loss and<br />
are scheduled<br />
to undergo<br />
elective,<br />
noncardiac,<br />
nonvascular<br />
surgery to<br />
reduce the<br />
need for<br />
allogeneic<br />
blood<br />
transfusions).<br />
Anemia due to<br />
myelodysplast<br />
ic syndrome<br />
(MDS).<br />
Anemia<br />
associated<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
8 wks of tx.Continued<br />
EA is not<br />
reasonable/necessary if<br />
there is a rapid Hb rise<br />
more than 1.0 g/dL (Hct<br />
more than 3%) over 2<br />
wks of tx unless Hb<br />
remains below or<br />
subsequently falls to less<br />
than 10.0 g/dL (or Hct is<br />
less than<br />
30%).Continuation/reins<br />
titution of EA must have<br />
dose reduction of 25% of<br />
previous dose. MDS,<br />
approve if Hb is 12.0<br />
g/dL or less.Previously<br />
receiving Aranesp or<br />
EA, approve if Hb is<br />
12.0 g/dL or less. An<br />
additional 6 months<br />
allowed after first 6<br />
months if Hb is 12.0<br />
g/dL or less. Anemia in<br />
HIV (with or without<br />
zidovudine), Hb is 10.0<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
once by 25%.<br />
Continued<br />
epoetin alfa use<br />
is not reasonable<br />
or necessary if<br />
the Hb rise is<br />
less than 1.0<br />
g/dL (or Hct is<br />
less than 3%)<br />
compared to<br />
pretreatment<br />
baseline by 8<br />
weeks of<br />
treatment.<br />
Continued<br />
epoetin alfa<br />
administation is<br />
not reasonable<br />
and necessary if<br />
there is a rapid<br />
rise in Hb or<br />
more than 1.0<br />
g/dL (or Hct<br />
more than 3%)<br />
over 2 weeks of<br />
treatment unless<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
69
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
with use of<br />
ribavirin<br />
therapy for<br />
hepatitis C (in<br />
combination<br />
with interferon<br />
or pegylated<br />
interferon alfa<br />
2a/2b<br />
products).<br />
Anemia in<br />
HIV-infected<br />
patients.<br />
Anemia in<br />
heart failure<br />
(HF).<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
g/dL or less or<br />
endogenous<br />
erythropoetin levels are<br />
500 munits/mL or less at<br />
tx start.Previously on EA<br />
approve if Hb is 12.0<br />
g/dL or less.Anemia due<br />
to ribavirin for Hep C,<br />
Hb is 10.0 g/dL or less at<br />
tx start. All conds, deny<br />
if Hb exceeds 12.0 g/dL.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
the Hb remains<br />
below or<br />
subsequently<br />
falls to less than<br />
10.0 g/dL (or<br />
Hct less than<br />
30%).<br />
Continuation<br />
and reinstitution<br />
of epoetin alfa<br />
must include a<br />
dose reduction<br />
of 25% from the<br />
previously<br />
administered<br />
dose.<br />
Continuation<br />
and reinstitution<br />
of Aranesp must<br />
include a dose<br />
reduction of<br />
25% from the<br />
previously<br />
administered<br />
dose. Anemia in<br />
HF, approve<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
70
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
initial trial of up<br />
to 2 months for<br />
patients with<br />
more severe HF,<br />
Hb of 10.0 g/dL<br />
or less, anemia<br />
persists despite<br />
transfusions or<br />
pt has<br />
contraindication<br />
s to transfusions.<br />
Deny if Hb is<br />
more than 12.0<br />
g/dL. Further<br />
approval after<br />
initial course<br />
will be<br />
determined on a<br />
case-by-case<br />
basis after<br />
evaluation by a<br />
pharmacist<br />
and/or<br />
physician.<br />
Anemia of<br />
chronic disease,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
71
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
approve initial<br />
trial of 3 months<br />
for patients with<br />
symptomatic<br />
anemia of 10.0<br />
g/dL or less,<br />
anemia persists<br />
despite<br />
transfusions or<br />
cannot tolerate<br />
or undergo<br />
transfusions,<br />
and/or low<br />
erythropoietin<br />
levels ot failure<br />
of other<br />
treatment<br />
modalities (eg,<br />
iron<br />
supplementation<br />
). Other causes<br />
of anemia have<br />
been ruled out.<br />
Deny if Hb is<br />
more than 12.0<br />
g/dL. Further<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
72
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
approval after<br />
initial course<br />
will be<br />
determined on a<br />
case-by-case<br />
basis after<br />
evaluation by a<br />
pharmacist<br />
and/or<br />
physician.<br />
Treatment of<br />
AA, approve<br />
initial trial of up<br />
to 1 month for<br />
patients with<br />
symptomatic<br />
anemia of less<br />
than 11.0 g/dL.<br />
Deny if Hb is<br />
more than 12.0<br />
g/dL. Further<br />
approval after<br />
initial course<br />
will be<br />
determined on a<br />
case-by-case<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
73
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ERBITUX<br />
SOLN 2<br />
ERIVEDGE<br />
CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
74<br />
OTHER<br />
CRITERIA<br />
basis after<br />
evaluation by a<br />
pharmacist<br />
and/or<br />
physician.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from N/A N/A N/A<br />
Restricted to or in<br />
consult with<br />
Oncology<br />
Specialist.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
estazolam tab 1<br />
etoposide inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Part D. All<br />
medically<br />
accepted<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDA<br />
approved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
<strong>Prior</strong> <strong>Authorization</strong><br />
required for<br />
members 65 and<br />
older<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
change and<br />
member<br />
eligibility.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
75<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
EXTAVIA INJ. 2<br />
fentanyl lollipop 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Prescribed by or<br />
after consultation<br />
with a neurologist<br />
or an MS<br />
specialist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
For breakthrough <strong>Authorization</strong><br />
chronic pain, will be for 12<br />
prescriber is a pain months, unless<br />
management otherwise<br />
specialist. specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
76<br />
OTHER<br />
CRITERIA<br />
N/A<br />
For<br />
breakthrough<br />
pain in patients<br />
with cancer and<br />
for breakthrough<br />
chronic (noncancer)<br />
pain, if<br />
patient is unable<br />
to swallow, has<br />
dysphagia,<br />
esophagitis,<br />
mucositis, or<br />
uncontrollable<br />
nausea/vomiting<br />
OR patient is
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
unable to take 2<br />
other shortacting<br />
narcotics<br />
(eg, oxycodone,<br />
morphine<br />
sulfate,<br />
hydromorphone,<br />
etc) secondary<br />
to allergy or<br />
severe adverse<br />
events AND<br />
patient is on or<br />
will be on a<br />
long-acting<br />
narcotic (eg,<br />
Duragesic), or<br />
the patient is on<br />
intravenous,<br />
subcutaneous, or<br />
spinal<br />
(intrathecal,<br />
epidural)<br />
narcotics (eg,<br />
morphine<br />
sulfate,<br />
hydromorphone,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
77
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
FIRMAGON<br />
INJ 2<br />
fludarabine inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
78<br />
OTHER<br />
CRITERIA<br />
fentanyl citrate).<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
fluorouracil inj. 1<br />
FOLOTYN INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
79<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
FORTEO SOLN. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
For<br />
hypoparathyroidis <strong>Authorization</strong><br />
m, the patient must will be for 12<br />
be under the care months, unless<br />
of an<br />
otherwise<br />
endocrinologist. specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
80<br />
OTHER<br />
CRITERIA<br />
Forteo may be<br />
approved for the<br />
covered<br />
osteoporosis<br />
indications if the<br />
patient has tried<br />
an oral or<br />
intravenous<br />
bisphosphonate<br />
(eg, alendronate,<br />
risedronate,<br />
ibandronate,<br />
zoledronic acid
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
FREAMINE III<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
81<br />
OTHER<br />
CRITERIA<br />
[Reclast]), or if<br />
the patient has<br />
severe renal<br />
impairment (eg,<br />
creatinine<br />
clearance less<br />
than 30<br />
mL/min) or<br />
chronic kidney<br />
disease, or if the<br />
patient has<br />
multiple<br />
vertebral<br />
fractures.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
gemcitabine inj. 1<br />
gengraf cap 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
82<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
gengraf soln. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
83<br />
OTHER<br />
CRITERIA
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
GILENYA<br />
CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For use in Multiple<br />
Sclerosis (MS), patient<br />
has a relapsing form of<br />
MS.<br />
AGE<br />
RESTRICTION<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
Prescribed by a<br />
neurologist or an<br />
MS specialist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
OTHER<br />
CRITERIA<br />
For use in MS,<br />
patient has a<br />
relapsing form<br />
of MS and<br />
patient has tried<br />
interferon beta-<br />
1a intramuscular<br />
(Avonex),<br />
interferon beta-<br />
1a subcutaneous<br />
(Rebif),<br />
interferon beta-<br />
1b (Betaseron or<br />
Extavia), or<br />
glatiramer<br />
acetate<br />
(Copaxone).<br />
Exceptions to<br />
having tried an<br />
interferon beta-<br />
1a or -1b<br />
product<br />
(Avonex,<br />
Betaseron,<br />
Extavia, or<br />
Rebif) or<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
84
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
85<br />
OTHER<br />
CRITERIA<br />
glatiramer<br />
acetate<br />
(Copaxone) can<br />
be made if the<br />
patient is unable<br />
to administer<br />
injections due to<br />
dexterity issues<br />
or visual<br />
impairment.<br />
Patients who<br />
have tried<br />
natalizumab<br />
(Tysabri) for<br />
MS and have a<br />
relapsing form<br />
of MS will<br />
receive<br />
authorization,<br />
they are not<br />
required to try<br />
an interferon<br />
beta product or<br />
glatiramer<br />
acetate.<br />
GLEEVEC TAB 2 All medically- N/A Diagnosis for which N/A N/A <strong>Authorization</strong> For CML, new
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
granisetron inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
accepted<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Gleevec is being used.<br />
For indications of CML<br />
and ALL, the<br />
Philadelphia<br />
chromosome (Ph) status<br />
of the leukemia must be<br />
reported. New patients<br />
with CML and ALL<br />
which is Ph-positive<br />
may receive<br />
authorization for<br />
Gleevec.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
will be for 12<br />
months.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
86<br />
OTHER<br />
CRITERIA<br />
patient must<br />
have Ph-positive<br />
CML for<br />
approval of<br />
Gleevec. For<br />
ALL, new<br />
patient must<br />
have Ph-positive<br />
ALL for<br />
approval of<br />
Gleevec.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
granisetron tab 1<br />
GRANISOL<br />
SOLN. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
87<br />
OTHER<br />
CRITERIA
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
HALAVEN<br />
make the<br />
INJ. 2 determination. N/A N/A N/A N/A N/A N/A<br />
heparin inj. 1 This drug may N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
88
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
heparin sodium /<br />
d5w inj 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
89<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
heparin/nacl inj. 1<br />
HEPATASOL<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
90<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
HERCEPTIN<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
91<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
HIZENTRA<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
The type of primary<br />
humoral<br />
immunodeficiency or<br />
primary<br />
immunodeficiency<br />
(PID).<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
92<br />
N/A<br />
Primary<br />
immunodeficiency<br />
(PID) or primary<br />
humoral<br />
immunodeficiency,<br />
if prescribed by a<br />
or in consultation<br />
with an<br />
allergist/immunolo<br />
gist, immunologist,<br />
otolaryngologist<br />
(ear nose and<br />
throat [ENT]<br />
physician), or an<br />
infectious disease<br />
physician who<br />
treats patients with<br />
PID/primary<br />
humoral<br />
immunodeficiency.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
OTHER<br />
CRITERIA<br />
Approve for<br />
patients with<br />
PID or primary<br />
humoral<br />
immunodeficien<br />
cy if they have<br />
previously<br />
received<br />
immune<br />
globulin given<br />
intravenously<br />
(IV) (eg,<br />
Carimune,<br />
Privigen, etc.) or<br />
immune<br />
globulin given<br />
subcutaneously<br />
(SC). Approve<br />
for patients with<br />
PID who have<br />
been previously<br />
treated with<br />
immune<br />
globulin therapy<br />
given
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
subcutaneously<br />
(SC) or who are<br />
continuing<br />
subcutaneous<br />
immune<br />
globulin therapy<br />
previously<br />
started.<br />
Exceptions may<br />
be given for<br />
patients with<br />
PID/primary<br />
humoral<br />
immunodeficien<br />
cy without prior<br />
IV or SC<br />
immune<br />
globulin use.<br />
HUMIRA KIT 2<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
For the treatment of RA<br />
member must have tried<br />
and failed Enbrel and<br />
Cimzia. For the<br />
treatment of Plaque<br />
Psoriasis, Psoriatic<br />
Arthritis or ankylosing<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
93<br />
N/A<br />
Rheumatoid<br />
Arthritis, Psoriatic<br />
Arthritis, Reactive<br />
Arthritis and<br />
Ankylosing<br />
Spondylitis=<br />
prescriber must be<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
hydroxyzine<br />
pamoate cap 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
spondylitis must have<br />
tried and failed Enbrel.<br />
For the treatment of<br />
Crohn's Disease must<br />
have tried and failed<br />
Cimzia<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
a Rheumatologist. eligibility.<br />
Crohn's Disease=<br />
prescriber must be<br />
a<br />
Gastroenterologist.<br />
Plaque Psoriasis=<br />
prescriber must be<br />
a Dermatologist.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
94<br />
OTHER<br />
CRITERIA<br />
Approve if the<br />
patient has tried<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,<br />
desloratadine,<br />
levocetirizine,<br />
fexofenadine/ps<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current<br />
condition.
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
Approve<br />
promethazine<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
diphenhydramin<br />
e (capsules or<br />
elixir) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
95
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
hydroxyzine<br />
syrup 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
96<br />
OTHER<br />
CRITERIA<br />
insomnia.<br />
Approve<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
Approve if the<br />
patient has tried<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,<br />
desloratadine,
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
levocetirizine,<br />
fexofenadine/ps<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current<br />
condition.<br />
Approve<br />
promethazine<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
diphenhydramin<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
97
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
hydroxyzine tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
98<br />
N/A<br />
<strong>Authorization</strong><br />
will be for 12<br />
OTHER<br />
CRITERIA<br />
e (capsules or<br />
elixir) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
insomnia.<br />
Approve<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
Approve if the<br />
patient has tried
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
months, unless<br />
otherwise<br />
specified.<br />
OTHER<br />
CRITERIA<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,<br />
desloratadine,<br />
levocetirizine,<br />
fexofenadine/ps<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current<br />
condition.<br />
Approve<br />
promethazine<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
99
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
diphenhydramin<br />
e (capsules or<br />
elixir) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
insomnia.<br />
Approve<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
100
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
idarubicin inj 1<br />
ifosfamide inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
101<br />
OTHER<br />
CRITERIA<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
INLYTA TAB 2<br />
intralipid inj. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. All<br />
medically<br />
accepted<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Restricted to or in<br />
consult with<br />
Oncology<br />
Specialist.<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
N/A<br />
This drug may<br />
be covered N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
102<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ipratropium neb 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
103<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ipratropium/<br />
albuterol soln. 1<br />
irinotecan inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
104<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ISTODAX INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
105<br />
OTHER<br />
CRITERIA
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
itraconazole cap 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Tinea<br />
corporis.<br />
Tinea cruris,<br />
faciei,<br />
manuum,<br />
imbricata, and<br />
pedis<br />
(nonmoccasin<br />
or chronic<br />
type). Plantaror<br />
moccasintype<br />
dry tinea<br />
pedis. Tinea or<br />
pityriasis<br />
versicolor.<br />
Tinea capitis.<br />
Tinea barbae.<br />
Treatment of<br />
vaginal<br />
candidiasis.<br />
Prevention of N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Onychomycosis must be<br />
judged to be medically<br />
significant (causing<br />
impaired mobility,<br />
discomfort, or in the<br />
presence of diabetes<br />
mellitus, an<br />
immunocompromised<br />
condition) by the<br />
treating physician and a<br />
positive KOH, fungal<br />
culture, DTM culture,<br />
nail biopsy, or histologic<br />
examination (PAS) is<br />
required before therapy<br />
initiation. Before a<br />
second course of<br />
treatment is permitted<br />
for onychomycosis, a<br />
culture must demonstrate<br />
a fungal infection. Use<br />
of topical ciclopirox 8%<br />
solution with<br />
itraconazole is not<br />
permitted. Itraconazole<br />
should not be given for N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
N/A<br />
COVERAGE<br />
DURATION<br />
Ony=12wks<br />
toenails,8wks<br />
fingernails.Cand<br />
ida ony,4<br />
mos.Other<br />
conds=12mos.<br />
OTHER<br />
CRITERIA<br />
Tinea corporis<br />
after a trial of a<br />
topical<br />
antifungal agent,<br />
except for<br />
extensive<br />
conditions.<br />
Tinea cruris,<br />
faciei, manuum,<br />
imbricata, and<br />
pedis<br />
(nonmoccasin or<br />
chronic type)<br />
after a trial of a<br />
topical<br />
antifungal agent.<br />
Tinea or<br />
pityriasis<br />
versicolor after<br />
trial of a topical<br />
antifungal agent,<br />
except for<br />
extensive<br />
conditions.<br />
Treatment of<br />
vaginal<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
106
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
recurrent<br />
vulvovaginal<br />
or vaginal<br />
candidiasis.<br />
Treatment or<br />
prevention of<br />
other<br />
superficial,<br />
systemic or<br />
suspected<br />
fungal<br />
infections.<br />
Patient has<br />
been started<br />
and stabilized<br />
on intravenous<br />
(IV)<br />
itraconazole<br />
therapy or oral<br />
itraconazole<br />
for a systemic<br />
infection and<br />
it is being<br />
used as<br />
continuation<br />
therapy.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
the treatment of<br />
onychomycosis in<br />
patients with CHF.<br />
Itraconazole is permitted<br />
for the treatment of<br />
patients with Candida<br />
onychomycosis if they<br />
have a culture positive<br />
for Candida.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
candidasis after<br />
a trial of oral<br />
fluconazole.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
107
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
IXEMPRA INJ 2<br />
JAKAFI TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Candida<br />
onychomycosi<br />
s.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. All<br />
medically N/A N/A N/A<br />
Restricted to or in<br />
consult with<br />
Oncology<br />
Specialists.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
108<br />
OTHER<br />
CRITERIA<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
JEVTANA INJ. 2<br />
KALYDECO<br />
TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
accepted<br />
eligibility.<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from N/A N/A N/A<br />
Restricted to or in<br />
consult with<br />
Pulmonology<br />
Specialist.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
109<br />
OTHER<br />
CRITERIA<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
KEPIVANCE<br />
INJ 2<br />
KINERET INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Part D. All<br />
medically<br />
accepted<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
change and<br />
member<br />
eligibility.<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
Rheumatoid<br />
Approved for<br />
arthritis (RA) and<br />
duration of<br />
indications not N/A<br />
N/A<br />
Still's disease, N/A<br />
contract year<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
110<br />
OTHER<br />
CRITERIA<br />
Adults with RA.<br />
Tried<br />
adalimumab,
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
otherwise<br />
excluded from<br />
Part D.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
OTHER<br />
CRITERIA<br />
certolizumab<br />
pegol,<br />
golimumab,<br />
etanercept, or<br />
infliximab for at<br />
least 2 months<br />
or was intolerant<br />
to one of these<br />
therapies.<br />
JIA/JRA<br />
(regardless of<br />
onset), approve<br />
if patient has<br />
tried etanercept,<br />
adalimumab,<br />
infliximab, or<br />
abatacept for at<br />
least 2 months<br />
or was intolerant<br />
to one of these<br />
therapies.<br />
Systemic onset<br />
of JIA, approve<br />
if patient has<br />
tried a systemic<br />
corticosteroid<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
111
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
(CS).<br />
Ankylosing<br />
spondylitis,<br />
approve if the<br />
patient has tried<br />
etanercept,<br />
infliximab,<br />
golimumab, or<br />
adalimumab for<br />
at least 2 months<br />
or was intolerant<br />
to one of these<br />
therapies. SD,<br />
approve if<br />
patient has tried<br />
a CS and has<br />
had an<br />
inadequate<br />
response to 1<br />
non-biologic<br />
DMARD (eg,<br />
methotrexate)<br />
for at least 2<br />
months or was<br />
intolerant to this<br />
therapy. MWS,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
112
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
approve if<br />
patient has tried<br />
two other drugs<br />
(rilonacept,<br />
canakinumab,<br />
colchicine, CS,<br />
chlorambucil,<br />
antihistamines,<br />
dapsone,<br />
azathioprine,<br />
mycophenolate<br />
mofetil) for<br />
MWS. FCAS,<br />
approve if<br />
patient has tried<br />
two other drugs<br />
(eg, colchicine,<br />
CS,<br />
antihistamines,<br />
azathioprine,<br />
mycophenolate<br />
mofetil,<br />
rilonacept, or<br />
canakinumab)<br />
for FCAS.<br />
Schnitzler's<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
113
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
syndrome,<br />
approve if<br />
patient has tried<br />
one other<br />
prescription<br />
medication used<br />
in Schnitzler's<br />
syndrome (eg,<br />
NSAIDs,<br />
antihistamines,<br />
colchicine, CS,<br />
immunosuppres<br />
sive drugs).<br />
Acute gout,<br />
patient has tried<br />
2 standard<br />
therapies for<br />
acute gout (eg,<br />
NSAIDs,<br />
colchicine, CS)<br />
or patient cannot<br />
tolerate or has<br />
contraindication<br />
s to standard<br />
therapies. FMF,<br />
approve in<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
114
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
LETAIRIS TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Patients<br />
currently on<br />
Letairis or<br />
Tracleer for<br />
treatment of<br />
pulmonary<br />
arterial<br />
hypertension. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For the FDA-approved<br />
indication of pulmonary<br />
arterial hypertension,<br />
patients not currently on<br />
Letairis or Tracleer are<br />
required to have had a<br />
right-heart<br />
catheterization to<br />
confirm the diagnosis of<br />
PAH to ensure<br />
appropriate medical<br />
assessment. For the<br />
FDA-approved<br />
indication of pulmonary<br />
arterial hypertension,<br />
patients currently on<br />
Letairis or Tracleer may<br />
continue therapy if they<br />
have a diagnosis of N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
For treatment of<br />
pulmonary arterial<br />
hypertension,<br />
Letairis or Tracleer<br />
must be prescribed<br />
by or in<br />
consultation with a<br />
cardiologist or a<br />
pulmonologist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
115<br />
OTHER<br />
CRITERIA<br />
patients who<br />
have tried<br />
colchicine.<br />
TRAPS,<br />
approve in<br />
patients who<br />
have tried CS.<br />
Digital ulcers,<br />
approve<br />
Tracleer if the<br />
patient has tried<br />
two other<br />
therapies for this<br />
condition such<br />
as calcium<br />
channel blockers<br />
(eg, amlodipine,<br />
felodipine,<br />
isradipine,<br />
nifedipine),<br />
alpha-adrenergic<br />
blockers (eg,<br />
prazosin),<br />
nitroglycerin,<br />
phosphodiestera<br />
se-5 inhibitors
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
LEUKINE INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
116<br />
OTHER<br />
CRITERIA<br />
PAH.<br />
(eg, sildenafil,<br />
vardenafil), or<br />
angiotensinconverting<br />
enzyme<br />
inhibitors (ACE<br />
inhibitors), or<br />
the patient has<br />
tried one<br />
vasodilator<br />
product (eg,<br />
intravenous<br />
epoprostenol,<br />
intravenous<br />
alprostadil).<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
leuprolide inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D but<br />
specific to the<br />
following<br />
drugs as<br />
follows:<br />
Prostate<br />
cancer<br />
(Lupron Depot<br />
OR Eligard),<br />
Endometriosis<br />
(Lupon<br />
Depot),<br />
Uterine<br />
leiomyomata<br />
(Lupon<br />
Depot), N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
117<br />
OTHER<br />
CRITERIA<br />
Premenstrual<br />
syndrome<br />
(PMS) for<br />
patients that<br />
have tried two<br />
other therapies<br />
(e.g., selective<br />
serotonin<br />
reuptake<br />
inhibitors<br />
[SSRIs], oral<br />
contraceptives<br />
[OCs]).<br />
For<br />
Menstrual<br />
dysfunctional migraine<br />
uterine bleeding approve if the<br />
approve for up patient has tried<br />
to 6 months and two other<br />
all other therapies for the<br />
indications x 12 treatment of<br />
mos. acute migraine
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
levalbuterol neb 1<br />
levocarnitine inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Treatment of<br />
central<br />
precocious<br />
puberty<br />
(Lupron Depot<br />
Ped).<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
118<br />
OTHER<br />
CRITERIA<br />
(e.g., NSAIDs,<br />
triptans,<br />
ergotamines) or<br />
prophylaxis of<br />
migraine (e.g.,<br />
beta-blockers,<br />
amitriptyline,<br />
divalproex).
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
levocarnitine<br />
soln. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
119<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
levocarnitine tab 1<br />
LIDODERM<br />
PATCH 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
<strong>Authorization</strong><br />
indications not<br />
will be for 12<br />
otherwise<br />
months, unless<br />
excluded from<br />
otherwise<br />
Part D. N/A N/A N/A N/A<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
120<br />
OTHER<br />
CRITERIA<br />
Myofascial pain<br />
as adjunctive<br />
therapy.<br />
Approve if<br />
being used in<br />
combination
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
with a standard<br />
myofascial<br />
trigger point<br />
(MTP) treatment<br />
modalities (e.g.,<br />
physical<br />
therapy, MTP<br />
injections of<br />
local anesthetic,<br />
relaxation<br />
techniques).<br />
Low back pain.<br />
Approve after<br />
trying two other<br />
pharmacologic<br />
therapies<br />
commonly used<br />
to treat low back<br />
pain (e.g.,<br />
acetaminophen,<br />
nonsteroidal<br />
antiinflammatory<br />
agents<br />
[NSAIDs],<br />
muscle<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
121
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
relaxants,<br />
opioids,<br />
cyclooxygenase-<br />
2 [COX-2]<br />
inhibitors,<br />
tramadol,<br />
gabapentin,<br />
tricyclic<br />
antidepressants<br />
[amitriptyline]).<br />
OA, approve<br />
after trying at<br />
least two other<br />
pharmacologic<br />
therapies (e.g.,<br />
acetaminophen,<br />
COX-2<br />
inhibitors,<br />
NSAIDs,<br />
salicylates,<br />
tramadol,<br />
opioids,<br />
intraarticular<br />
glucocorticoids,<br />
topical<br />
capsaicin,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
122
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
LIPOSYN III<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
123<br />
OTHER<br />
CRITERIA<br />
topical<br />
methylsalicylate<br />
, or intraarticular<br />
hyaluronan).<br />
Carpal tunnel<br />
syndrome.<br />
Approve after a<br />
trying one other<br />
pharmacological<br />
therapy used to<br />
treat carpal<br />
tunnel syndrome<br />
(e.g., steroids<br />
[oral or<br />
injectable],<br />
NSAIDs).<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
LUPRON<br />
DEPOT INJ.<br />
3.75MG 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D but<br />
specific to the<br />
following<br />
drugs as<br />
follows:<br />
Prostate<br />
cancer<br />
(Lupron Depot<br />
OR Eligard),<br />
Endometriosis<br />
(Lupon<br />
Depot),<br />
Uterine<br />
leiomyomata<br />
(Lupon N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
124<br />
OTHER<br />
CRITERIA<br />
Premenstrual<br />
syndrome<br />
(PMS) for<br />
patients that<br />
have tried two<br />
other therapies<br />
(e.g., selective<br />
serotonin<br />
reuptake<br />
inhibitors<br />
[SSRIs], oral<br />
contraceptives<br />
For<br />
[OCs]).<br />
dysfunctional Menstrual<br />
uterine bleeding migraine<br />
approve for up approve if the<br />
to 6 months and patient has tried<br />
all other two other<br />
indications x 12 therapies for the<br />
mos. treatment of
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
LUPRON<br />
DEPOT INJ.<br />
7.5MG, 22.5MG,<br />
30MG, 45MG 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Depot),<br />
Treatment of<br />
central<br />
precocious<br />
puberty<br />
(Lupron Depot<br />
Ped).<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D but<br />
specific to the<br />
following<br />
drugs as<br />
follows:<br />
Prostate<br />
cancer<br />
(Lupron Depot<br />
OR Eligard),<br />
Endometriosis<br />
(Lupon<br />
Depot), N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
125<br />
OTHER<br />
CRITERIA<br />
acute migraine<br />
(e.g., NSAIDs,<br />
triptans,<br />
ergotamines) or<br />
prophylaxis of<br />
migraine (e.g.,<br />
beta-blockers,<br />
amitriptyline,<br />
divalproex).<br />
Premenstrual<br />
syndrome<br />
(PMS) for<br />
patients that<br />
have tried two<br />
other therapies<br />
(e.g., selective<br />
serotonin<br />
reuptake<br />
For<br />
inhibitors<br />
dysfunctional [SSRIs], oral<br />
uterine bleeding contraceptives<br />
approve for up [OCs]).<br />
to 6 months and Menstrual<br />
all other migraine<br />
indications x 12 approve if the<br />
mos. patient has tried
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
LUPRON<br />
DEPOT<br />
PEDIATRIC<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Uterine<br />
leiomyomata<br />
(Lupon<br />
Depot),<br />
Treatment of<br />
central<br />
precocious<br />
puberty<br />
(Lupron Depot<br />
Ped).<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D but<br />
specific to the<br />
following<br />
drugs as<br />
follows:<br />
Prostate<br />
cancer<br />
(Lupron Depot<br />
OR Eligard), N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
126<br />
OTHER<br />
CRITERIA<br />
two other<br />
therapies for the<br />
treatment of<br />
acute migraine<br />
(e.g., NSAIDs,<br />
triptans,<br />
ergotamines) or<br />
prophylaxis of<br />
migraine (e.g.,<br />
beta-blockers,<br />
amitriptyline,<br />
divalproex).<br />
Premenstrual<br />
syndrome<br />
(PMS) for<br />
patients that<br />
have tried two<br />
other therapies<br />
For<br />
(e.g., selective<br />
dysfunctional serotonin<br />
uterine bleeding reuptake<br />
approve for up inhibitors<br />
to 6 months and [SSRIs], oral<br />
all other contraceptives<br />
indications x 12 [OCs]).<br />
mos. Menstrual
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
melphalan inj. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Endometriosis<br />
(Lupon<br />
Depot),<br />
Uterine<br />
leiomyomata<br />
(Lupon<br />
Depot),<br />
Treatment of<br />
central<br />
precocious<br />
puberty<br />
(Lupron Depot<br />
Ped).<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
127<br />
OTHER<br />
CRITERIA<br />
migraine<br />
approve if the<br />
patient has tried<br />
two other<br />
therapies for the<br />
treatment of<br />
acute migraine<br />
(e.g., NSAIDs,<br />
triptans,<br />
ergotamines) or<br />
prophylaxis of<br />
migraine (e.g.,<br />
beta-blockers,<br />
amitriptyline,<br />
divalproex).
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
methocarbamol<br />
tab 1<br />
methotrexate inj 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 1<br />
month.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
128<br />
OTHER<br />
CRITERIA<br />
Musculoskeletal<br />
conditions/disor<br />
ders, approve if<br />
the patient has<br />
tried two other<br />
therapies for the<br />
current<br />
condition.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
methotrexate tab 1<br />
MIACALCIN<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
129<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
mitomycin inj. 1<br />
mitoxantrone inj 1 This drug may N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
130<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
modafanil tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For the FDA-approved<br />
indication of excessive<br />
sleepiness due to<br />
obstructive sleep<br />
apnea/hypoapnea<br />
syndrome (OSAHS)<br />
patients must have tried<br />
continuous positive<br />
airway pressure (CPAP).<br />
For the FDA-approved<br />
indication of excessive<br />
AGE<br />
RESTRICTION<br />
ADHD or ADD in<br />
patients less than<br />
18 years.<br />
Adjunctive<br />
augmentation<br />
treatment for<br />
depression must be<br />
in adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
Idiopathic<br />
hypersomnia must<br />
have the diagnosis<br />
confirmed by a<br />
sleep specialist<br />
physician or at an<br />
institution that<br />
specializes in sleep<br />
disorders.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
131<br />
OTHER<br />
CRITERIA<br />
Excessive<br />
sleepiness due<br />
to OSAHS if the<br />
patient has tried<br />
CPAP.<br />
Excessive<br />
sleepiness due<br />
to SWSD if the<br />
patient is<br />
working at least<br />
5 overnight
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
sleepiness due to shiftwork<br />
sleep disorder<br />
(SWSD), patients must<br />
be working at least 5<br />
overnight shifts per<br />
month.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
shifts per month.<br />
ADHD/ADD<br />
who have tried<br />
two alternative<br />
medications for<br />
ADHD/ADD<br />
from two<br />
different classes<br />
as follows:<br />
methylphenidate<br />
products (e.g.,<br />
methylphenidate<br />
,<br />
dexmethylpheni<br />
date),<br />
amphetamines<br />
(e.g., mixed<br />
amphetamine<br />
salts,<br />
dextroamphetam<br />
ine),<br />
atomoxetine,<br />
bupropion or<br />
tricyclic<br />
antidepressants<br />
(TCAs e.g.,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
132
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
MOZOBIL INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
133<br />
OTHER<br />
CRITERIA<br />
imipramine,<br />
desipramine).<br />
Adjunctive/aug<br />
mentation<br />
treatment for<br />
depression in<br />
adults if the<br />
patient is<br />
concurrently<br />
receiving other<br />
medication<br />
therapy for<br />
depression.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
mycophenolate<br />
cap 1<br />
mycophenolate<br />
tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
134<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
MYFORTIC<br />
TAB 2<br />
NAGLAZYME 2 This drug may N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
135<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
INJ.<br />
NEPHRAMINE<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
136<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Cancer patients<br />
receiving<br />
chemotherapy, if<br />
prescribed by or in<br />
consultation with<br />
an oncologist or<br />
hematologist.<br />
Radiation injury, if<br />
prescribed by, or in<br />
COVERAGE<br />
DURATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D but<br />
worded more<br />
broadly as<br />
Radiation injury,<br />
approve if the estimated<br />
whole body or<br />
significant partial-body<br />
exposure is at least 3<br />
Grays in adults aged less<br />
than 60 years, or at least<br />
2 Grays in children<br />
consultation with, a<br />
NEULASTA<br />
cancer patients<br />
receiving<br />
myelosuppress<br />
ive<br />
(aged 12 years or less) or<br />
in adults aged 60 years<br />
or older, or in those who<br />
have major trauma<br />
physician with<br />
experience in<br />
treating acute<br />
radiation<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
INJ. 2 chemotherapy. N/A<br />
injuries or burns. N/A<br />
syndrome. specified.<br />
NEUMEGA INJ. 2 This drug may N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
137<br />
OTHER<br />
CRITERIA<br />
Radiation<br />
injury, approve<br />
if the estimated<br />
whole body or<br />
significant<br />
partial-body<br />
exposure is at<br />
least 3 Grays in<br />
adults aged less<br />
than 60 years, or<br />
at least 2 Grays<br />
in children<br />
(aged 12 years<br />
or less) or in<br />
adults aged 60<br />
years or older,<br />
or in those who<br />
have major<br />
trauma injuries<br />
or burns.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
NEUPOGEN<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D worded<br />
more broadly<br />
as cancer<br />
patients<br />
receiving<br />
myelosuppressN/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Radiation injury,<br />
approve if the estimated<br />
whole body or<br />
significant partial-body<br />
exposure is at least 3<br />
Grays in adults aged less<br />
than 60 years, or at least<br />
2 Grays in children<br />
(aged 12 years or less) or<br />
in adults aged 60 years<br />
or older, or in those who N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Cancer/AML,<br />
PBPC, MDS, AA,<br />
ALL, oncologist or<br />
a hematologist.<br />
SCN, hematologist.<br />
HIV/AIDS<br />
neutropenia,<br />
infectious disease<br />
(ID) physician<br />
(MD),<br />
hematologist, or<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
138<br />
OTHER<br />
CRITERIA<br />
Radiation<br />
injury, approve<br />
if the estimated<br />
whole body or<br />
significant<br />
partial-body<br />
exposure is at<br />
least 3 Grays in<br />
adults aged less<br />
than 60 years, or<br />
at least 2 Grays
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
ive<br />
chemotherapy,<br />
patients with<br />
acute myeloid<br />
leukemia<br />
(AML)<br />
receiving<br />
chemotherapy,<br />
cancer patients<br />
receiving bone<br />
marrow<br />
transplantation<br />
(BMT),<br />
patients<br />
undergoing<br />
peripheral<br />
blood<br />
progenitor cell<br />
(PBPC)<br />
collection and<br />
therapy, and<br />
patients with<br />
severe chronic<br />
neutropenia<br />
[SCN] (e.g.,<br />
congenital<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
have major trauma<br />
injuries or burns.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
MD specializing in<br />
HIV/AIDS. RI, an<br />
MD with<br />
experience in<br />
treating acute<br />
radiation<br />
syndrome. RT, an<br />
oncologist,<br />
radiologist, or<br />
radiation<br />
oncologist.<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
in children<br />
(aged 12 years<br />
or less) or in<br />
adults aged 60<br />
years or older,<br />
or in those who<br />
have major<br />
trauma injuries<br />
or burns.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
139
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
neutropenia,<br />
cyclic<br />
neutropenia,<br />
idiopathic<br />
neutropenia).<br />
Neutropenia<br />
associated<br />
with human<br />
immunodefici<br />
ency virus<br />
(HIV) or<br />
acquired<br />
immunodefici<br />
ency<br />
syndrome<br />
(AIDS).<br />
Treatment of<br />
myelodysplast<br />
ic syndromes<br />
(MDS). <strong>Drug</strong><br />
induced<br />
agranulocytosi<br />
s or<br />
neutropenia.<br />
Aplastic<br />
anemia (AA).<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
140
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
NEXAVAR<br />
TAB 2<br />
NUEDEXTA<br />
CAP 2<br />
ondansetron inj 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Acute<br />
lymphocytic<br />
leukemia<br />
(ALL).<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Prescribed by a<br />
Oncologist or<br />
Require patient to under the direct<br />
be at least 18 years consultation of an<br />
old.<br />
Oncologist.<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
Part D. N/A N/A N/A N/A<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
141<br />
OTHER<br />
CRITERIA<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ondansetron odt<br />
tab 1<br />
ondansetron<br />
soln. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
142<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ondansetron tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
143<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ONFI TAB 2<br />
ONTAK INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDA<br />
approved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
<strong>Prior</strong> <strong>Authorization</strong><br />
required for<br />
members 65 and<br />
older<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
144<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ORENCIA INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
patients who<br />
have already<br />
been started<br />
on abatacept<br />
for a covered<br />
use. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Rheumatoid<br />
arthritis (RA),<br />
adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
145<br />
N/A<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
OTHER<br />
CRITERIA<br />
RA, approve if<br />
the patient has<br />
tried one of the<br />
following<br />
biologic<br />
DMARDs,<br />
adalimumab,<br />
etanercept,<br />
certolizumab<br />
pegol,<br />
golimumab, or<br />
infliximab for at<br />
least 2 months,<br />
or was intolerant<br />
to one of these<br />
therapies.<br />
Juvenile<br />
idiopathic<br />
arthritis (JIA)<br />
[or Juvenile<br />
Rheumatoid<br />
Arthritis (JRA)],<br />
polyarticular<br />
course, approve
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
orphenadrine<br />
compound ds tab 1<br />
orphenadrine<br />
citrate er tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 1<br />
month.<br />
<strong>Authorization</strong><br />
will be for 1<br />
month.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
146<br />
OTHER<br />
CRITERIA<br />
if the patient has<br />
tried one of the<br />
following<br />
biologic<br />
DMARDs,<br />
adalimumab,<br />
etanercept, or<br />
infliximab for at<br />
least 2 months<br />
or was intolerant<br />
to one of these<br />
therapies.<br />
Musculoskeletal<br />
conditions/disor<br />
ders, approve if<br />
the patient has<br />
tried two other<br />
therapies for the<br />
current<br />
condition.<br />
Musculoskeletal<br />
conditions/disor<br />
ders, approve if<br />
the patient has<br />
tried two other<br />
therapies for the
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
orphenadrine/asp<br />
irin/caffeine 1<br />
oxaliplatin inj 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 1<br />
month.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
147<br />
OTHER<br />
CRITERIA<br />
current<br />
condition.<br />
Musculoskeletal<br />
conditions/disor<br />
ders, approve if<br />
the patient has<br />
tried two other<br />
therapies for the<br />
current<br />
condition.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
paclitaxel inj 1<br />
pamidronate inj 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
148<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
PEGASYS INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Hepatitis C. depending<br />
on genotype, response in<br />
HCV RNA, liver<br />
fibrosis, HIV status, and<br />
HIV RNA. Chronic Hep<br />
C, on waiting list for<br />
liver transplant.<br />
Recurrent Hep C, after<br />
liver transplant, grade II<br />
fibrosis or greater. N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
For all pts with<br />
hepatitis C, must<br />
be prescribed by an<br />
infectious disease<br />
MD,<br />
gastroenterologist,<br />
hepatologist, or a<br />
transplant MD or<br />
in consultation<br />
with one of these<br />
MDs.<br />
COVERAGE<br />
DURATION<br />
Hep C. 12, 24,<br />
48, wks Acute<br />
hep C. 6 to 12<br />
mo Chronic hep<br />
C lvr trnplnt 12<br />
wks non-hep C<br />
12 mo<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
149<br />
OTHER<br />
CRITERIA<br />
Adult not<br />
previously txd<br />
for chronic<br />
hepatitis C (HC)<br />
w/ interferon<br />
alfa<br />
(IA)/peginterfer<br />
on alfa (PA) and<br />
not HIV coinfected,HC<br />
genotype 2/3<br />
authorize 24<br />
wks initial tx, or<br />
HC genotype 3<br />
w/ high level of<br />
HCV RNA (per<br />
MD) or<br />
advanced<br />
fibrosis<br />
authorize 48
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
wks (total), or<br />
HC genotypes<br />
1/4 authorize 12<br />
wks initial tx<br />
(document<br />
baseline HCV<br />
RNA) and<br />
reassess viral<br />
titer at 12 wks,<br />
if decreased by<br />
2log10 or more<br />
and virus is<br />
undetectable,<br />
authorize 36<br />
wks (total 48<br />
wks), or if not<br />
decreased by<br />
2log 10,<br />
authorize 12<br />
wks and<br />
reassess at 24<br />
wks, or<br />
genotype 1 w/<br />
viral titer<br />
decrease of<br />
2log10 but virus<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
150
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
still detectable,<br />
authorize 12<br />
wks and<br />
reassess at 24<br />
wks. At 24 wk,<br />
if advanced<br />
fibrosis (via<br />
liver bx) and<br />
undetectable<br />
virus, authorize<br />
24 wks (48 wks<br />
total), or if<br />
advanced<br />
fibrosis and<br />
detectable HCV<br />
RNA MD and pt<br />
to decide<br />
whether to cont<br />
w/ another 24<br />
wks OR If no<br />
advanced<br />
fibrosis and do<br />
not have greater<br />
than or equal to<br />
2 log10 decrease<br />
or virus<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
151
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
undetectable, no<br />
further<br />
authorization, or<br />
if genotype 1 w/<br />
2log10 decrease<br />
AND detectable<br />
virus at wk 12<br />
but no<br />
detectable virus<br />
at wk 24, then<br />
authorize for 48<br />
wksHC viral<br />
genotype 5/6<br />
use genotype<br />
1/4 criteria<br />
above.Coinfecte<br />
d with HIV/HC<br />
(genotype<br />
1,2,3,4) and not<br />
previously txd<br />
for HC,<br />
authorize up to<br />
48 wks<br />
(total).Child 2 to<br />
17 yrs w/HC<br />
(genotypes<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
152
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
1,2,3,4) not been<br />
previously txd<br />
for HC w/IA/PA<br />
AND not HIV<br />
co-infected,<br />
authorize 24<br />
wks initial tx. At<br />
24 wk, if viral<br />
titer<br />
undetectable<br />
after 24 wks or<br />
if viral titer<br />
decreased by<br />
2log10 or more<br />
after 12 wks of<br />
tx, authorize 24<br />
wks (48 wks<br />
total), or if viral<br />
titer still<br />
detectable after<br />
24 wks of tx,<br />
then no further<br />
authorization.Co<br />
infected w/ HC<br />
and Hep B,<br />
authorize 48<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
153
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
wks. Acute hep<br />
C (ie, infection<br />
within 6 mos of<br />
exposure),<br />
authorize 6 to 12<br />
mos of tx if at<br />
least 2 to 4 mos<br />
after acute<br />
onset.Retreatme<br />
nt of pts who<br />
have been<br />
previously txd<br />
for HC w/ IA or<br />
PA, authorize 48<br />
wks.<br />
Retreatment of<br />
pts who failed to<br />
attain a<br />
sustained<br />
virologic<br />
response (SVR)<br />
[undetectable<br />
HCV RNA at<br />
the end of<br />
txment and 24<br />
wks after txment<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
154
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
completion] w/<br />
PA and ribavirin<br />
is not<br />
recommended<br />
unless specific<br />
factors that<br />
contributed to<br />
the nonresponse<br />
are identified<br />
and corrected<br />
before retxment.<br />
Recurrent hep C<br />
after liver<br />
transplant and<br />
grade II fibrosis,<br />
authorize 48<br />
wks if PA<br />
prescribed by<br />
hepatologist or<br />
liver transplant<br />
MD affiliated w/<br />
liver transplant<br />
program.HC on<br />
waiting list for<br />
liver<br />
transplantation,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
155
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
authorize initial<br />
12 wks if<br />
administered in<br />
liver clinic<br />
affiliated with<br />
liver transplant<br />
program. At 12<br />
wks, genotype<br />
2/3 and viral<br />
titer decreased<br />
by 2log10 or<br />
more and virus<br />
undetectable<br />
authorize 24<br />
wks total from<br />
the time pt has<br />
achieved an<br />
optimal dose of<br />
PA and<br />
ribavirin, for<br />
genotype 1 and<br />
viral titer<br />
decreased by<br />
2log10 or more<br />
and virus<br />
undetectable<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
156
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
pentostatin inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
157<br />
OTHER<br />
CRITERIA<br />
authorize 52<br />
wks total from<br />
the time pt has<br />
achieved an<br />
optimal dose of<br />
PA and<br />
ribavirin, or<br />
genotype 1/2/3<br />
and viral titer<br />
not decreased by<br />
2log10, then no<br />
further<br />
authorization.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
PERFOROMIST<br />
NEB 2<br />
PERJETA INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
158<br />
OTHER<br />
CRITERIA<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
POTIGA TAB 2<br />
PRADAXA<br />
CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
use in patients<br />
with atrial<br />
flutter.<br />
Treatment of<br />
acute venous<br />
thromboembol<br />
ism.<br />
Prevention of<br />
venous<br />
thromboembol<br />
ism after hip N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
eligibility.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
159<br />
OTHER<br />
CRITERIA<br />
N/A<br />
Authorize use of<br />
Pradaxa for<br />
patients with<br />
non-valvular<br />
atrial fibrillation<br />
or flutter.<br />
<strong>Authorization</strong><br />
may be given<br />
for treatment of<br />
acute venous<br />
thromboembolis<br />
m (VTE),<br />
prevention of<br />
VTE after hip or<br />
knee<br />
replacement<br />
surgery, or
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
replacement<br />
surgery.<br />
Prevention of<br />
venous<br />
thromboembol<br />
ism after knee<br />
replacement<br />
surgery.<br />
Additional<br />
indications<br />
will be<br />
evaluated by a<br />
pharmacist<br />
and/or a<br />
physician on a<br />
case-by-case<br />
basis.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
additional<br />
indications<br />
evaluated by a<br />
pharmacist<br />
and/or a<br />
physician on a<br />
case-by-case<br />
basis, if the<br />
patient has tried<br />
one of the<br />
following<br />
therapies for the<br />
condition:<br />
warfarin<br />
(Coumadin),<br />
fondaparinux<br />
(Arixtra), or a<br />
low molecular<br />
weight heparin<br />
(LMWH)<br />
product<br />
(enoxaparin<br />
[Lovenox],<br />
tinzaparin<br />
[Innohep],<br />
dalteparin<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
160
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
[Fragmin]), OR<br />
if the patient is<br />
unable to take<br />
one of these<br />
medications<br />
listed for the<br />
condition for<br />
one of the<br />
following<br />
reasons: patient<br />
has allergic,<br />
immunologic or<br />
inherited<br />
disorder, patient<br />
had adverse<br />
effect (eg, major<br />
organ toxicity,<br />
major bleeding),<br />
the patient has<br />
experienced<br />
ineffectiveness<br />
to the agent in a<br />
prior setting, the<br />
patient has drugdrug<br />
interactions<br />
that cannot be<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
161
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
managed<br />
(warfarin), the<br />
patient lacks<br />
access to proper<br />
monitoring<br />
(warfarin), the<br />
patient has<br />
experienced<br />
prior heparininduced<br />
thrombocytopen<br />
ia (HIT) or<br />
heparin-induced<br />
thrombocytopen<br />
ia and<br />
thrombosis<br />
(HITT)<br />
(fondaparinux<br />
[Arixtra] or<br />
LMWH), or the<br />
patient is unable<br />
to perform<br />
injections or<br />
have injections<br />
administered to<br />
them<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
162
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
premasol soln. 2<br />
PROCALAMIN<br />
E INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
163<br />
OTHER<br />
CRITERIA<br />
(fondaparinux<br />
[Arixtra] or<br />
LMWH).<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
PROCRIT INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D worded<br />
as anemia<br />
associated<br />
with chronic<br />
renal failure<br />
(CRF),<br />
including<br />
patients on<br />
dialysis and<br />
not on<br />
dialysis, and<br />
worded as N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
CRF<br />
anemia.Hemoglobin<br />
(Hb) of less than or<br />
equal to 10.0 g/dL to<br />
start.Hb less than or<br />
equal to 12.0 g/dL if<br />
previously on epoetin<br />
alfa (EA) or<br />
Aranesp.Anemia<br />
w/myelosuppressive<br />
chemotx.Hb<br />
immediately prior to EA<br />
is 10.0 g/dL or less (or<br />
hematocrit [Hct] is 30%<br />
or less).EA maintenance<br />
is starting dose if Hb<br />
level remains 10.0 g/dL N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
AA, prescribed by<br />
a hematologist.<br />
COVERAGE<br />
DURATION<br />
Preop approval:<br />
1 month. All<br />
others initial<br />
appr 3months.<br />
Reauth at 3<br />
month intervals<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
164<br />
OTHER<br />
CRITERIA<br />
Part B versus<br />
Part D<br />
determination<br />
will be made at<br />
time of prior<br />
authorization<br />
review per CMS<br />
guidance to<br />
establish if the<br />
drug prescribed<br />
is to be used for<br />
an end-stage<br />
renal disease<br />
(ESRD)-related<br />
condition.<br />
Anemia<br />
secondary to
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
anemia<br />
secondary to<br />
myelosuppress<br />
ive anticancer<br />
chemotherapy<br />
in solid<br />
tumors,<br />
multiple<br />
myeloma,<br />
lymphoma,<br />
and<br />
lymphocytic<br />
leukemia. Plus<br />
anemia in<br />
patients with<br />
HIV who are<br />
receiving<br />
zidovudine.<br />
Anemic<br />
patients (Hb of<br />
13.0 g/dL or<br />
less) at high<br />
risk for<br />
perioperative<br />
transfusions<br />
(secondary to<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
or less (or Hct remains<br />
30% or less) 4 wks after<br />
start and Hb rise is 1.0<br />
g/dL or more (Hct rise is<br />
3% or more).Pts w/Hb<br />
rises less than 1.0 g/dL<br />
(Hct rise less than 3%)<br />
vs pretx baseline over 4<br />
wks of tx and Hb is less<br />
than 10.0 g/dL after 4<br />
wks of tx (Hct is less<br />
than 30%), the<br />
recommended FDA<br />
starting dose may be<br />
increased once by<br />
25%.Continued use is<br />
not reasonable/necessary<br />
if Hb rises less than 1.0<br />
g/dL (Hct rise less than<br />
3%) vs pretx baseline by<br />
8 wks of tx.Continued<br />
EA is not<br />
reasonable/necessary if<br />
there is a rapid Hb rise<br />
more than 1.0 g/dL (Hct<br />
more than 3%) over 2<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
myelosuppressiv<br />
e anticancer<br />
chemotherapy in<br />
solid tumors,<br />
multiple<br />
myeloma,<br />
lymphoma, and<br />
lymphocytic<br />
leukemia. Pts<br />
with Hb rise of<br />
less than 1.0<br />
g/dL (or Hct 3%<br />
or less) and Hb<br />
levels is less<br />
than 10.0 g/dL<br />
after 4 wks<br />
therapy, the<br />
recommended<br />
FDA dose may<br />
be increased<br />
once by 25%.<br />
Continued<br />
epoetin alfa use<br />
is not reasonable<br />
or necessary if<br />
the Hb rise is<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
165
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
significant,<br />
anticipated<br />
blood loss and<br />
are scheduled<br />
to undergo<br />
elective,<br />
noncardiac,<br />
nonvascular<br />
surgery to<br />
reduce the<br />
need for<br />
allogeneic<br />
blood<br />
transfusions).<br />
Anemia due to<br />
myelodysplast<br />
ic syndrome<br />
(MDS).<br />
Anemia<br />
associated<br />
with use of<br />
ribavirin<br />
therapy for<br />
hepatitis C (in<br />
combination<br />
with interferon<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
wks of tx unless Hb<br />
remains below or<br />
subsequently falls to less<br />
than 10.0 g/dL (or Hct is<br />
less than<br />
30%).Continuation/reins<br />
titution of EA must have<br />
dose reduction of 25% of<br />
previous dose. MDS,<br />
approve if Hb is 12.0<br />
g/dL or less.Previously<br />
receiving Aranesp or<br />
EA, approve if Hb is<br />
12.0 g/dL or less. An<br />
additional 6 months<br />
allowed after first 6<br />
months if Hb is 12.0<br />
g/dL or less. Anemia in<br />
HIV (with or without<br />
zidovudine), Hb is 10.0<br />
g/dL or less or<br />
endogenous<br />
erythropoetin levels are<br />
500 munits/mL or less at<br />
tx start.Previously on EA<br />
approve if Hb is 12.0<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
less than 1.0<br />
g/dL (or Hct is<br />
less than 3%)<br />
compared to<br />
pretreatment<br />
baseline by 8<br />
weeks of<br />
treatment.<br />
Continued<br />
epoetin alfa<br />
administation is<br />
not reasonable<br />
and necessary if<br />
there is a rapid<br />
rise in Hb or<br />
more than 1.0<br />
g/dL (or Hct<br />
more than 3%)<br />
over 2 weeks of<br />
treatment unless<br />
the Hb remains<br />
below or<br />
subsequently<br />
falls to less than<br />
10.0 g/dL (or<br />
Hct less than<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
166
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
or pegylated<br />
interferon alfa<br />
2a/2b<br />
products).<br />
Anemia in<br />
HIV-infected<br />
patients.<br />
Anemia in<br />
heart failure<br />
(HF).<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
g/dL or less.Anemia due<br />
to ribavirin for Hep C,<br />
Hb is 10.0 g/dL or less at<br />
tx start. All conds, deny<br />
if Hb exceeds 12.0 g/dL.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
30%).<br />
Continuation<br />
and reinstitution<br />
of epoetin alfa<br />
must include a<br />
dose reduction<br />
of 25% from the<br />
previously<br />
administered<br />
dose.<br />
Continuation<br />
and reinstitution<br />
of Aranesp must<br />
include a dose<br />
reduction of<br />
25% from the<br />
previously<br />
administered<br />
dose. Anemia in<br />
HF, approve<br />
initial trial of up<br />
to 2 months for<br />
patients with<br />
more severe HF,<br />
Hb of 10.0 g/dL<br />
or less, anemia<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
167
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
persists despite<br />
transfusions or<br />
pt has<br />
contraindication<br />
s to transfusions.<br />
Deny if Hb is<br />
more than 12.0<br />
g/dL. Further<br />
approval after<br />
initial course<br />
will be<br />
determined on a<br />
case-by-case<br />
basis after<br />
evaluation by a<br />
pharmacist<br />
and/or<br />
physician.<br />
Anemia of<br />
chronic disease,<br />
approve initial<br />
trial of 3 months<br />
for patients with<br />
symptomatic<br />
anemia of 10.0<br />
g/dL or less,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
168
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
anemia persists<br />
despite<br />
transfusions or<br />
cannot tolerate<br />
or undergo<br />
transfusions,<br />
and/or low<br />
erythropoietin<br />
levels ot failure<br />
of other<br />
treatment<br />
modalities (eg,<br />
iron<br />
supplementation<br />
). Other causes<br />
of anemia have<br />
been ruled out.<br />
Deny if Hb is<br />
more than 12.0<br />
g/dL. Further<br />
approval after<br />
initial course<br />
will be<br />
determined on a<br />
case-by-case<br />
basis after<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
169
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
170<br />
OTHER<br />
CRITERIA<br />
evaluation by a<br />
pharmacist<br />
and/or<br />
physician.<br />
Treatment of<br />
AA, approve<br />
initial trial of up<br />
to 1 month for<br />
patients with<br />
symptomatic<br />
anemia of less<br />
than 11.0 g/dL.<br />
Deny if Hb is<br />
more than 12.0<br />
g/dL. Further<br />
approval after<br />
initial course<br />
will be<br />
determined on a<br />
case-by-case<br />
basis after<br />
evaluation by a<br />
pharmacist<br />
and/or<br />
physician.<br />
PROGRAF INJ 2 This drug may N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
PROLASTIN<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Alpha-<br />
1 antitrypsin<br />
(AAT)<br />
deficiencyassociated<br />
panniculitis. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
For AAT deficiency<br />
with emphysema (or<br />
COPD), approve in<br />
patients with baseline<br />
(pretreatment) alpha1-<br />
antitrypsin serum<br />
concentration less than<br />
11 microM (11<br />
micromol/L) or 80<br />
mg/dL. N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
171<br />
OTHER<br />
CRITERIA<br />
For all covered<br />
uses, the patient<br />
is required to try<br />
Aralast NP first<br />
line. For AAT<br />
deficiency with<br />
emphysema (or<br />
COPD), approve<br />
in patients with<br />
baseline<br />
(pretreatment)
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
PROMACTA<br />
TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Thrombocytop<br />
enia due to<br />
hepatitis C<br />
virus (HCV)-<br />
related<br />
cirrhosis. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Cause of<br />
thrombocytopenia.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
172<br />
N/A<br />
Treatment of<br />
thrombocytopenia<br />
due to chronic<br />
immune<br />
(idiopathic)<br />
thrombocytopenic<br />
purpura (ITP),<br />
approve if<br />
prescribed by, or<br />
after consultation<br />
with, a<br />
hematologist.<br />
Treatment of<br />
thrombocytopenia<br />
due to HCVrelated<br />
cirrhosis,<br />
approve if<br />
prescribed by, or<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
OTHER<br />
CRITERIA<br />
alpha1-<br />
antitrypsin<br />
serum<br />
concentration<br />
less than 11<br />
microM (11<br />
micromol/L) or<br />
80 mg/dL.<br />
For treatment of<br />
thrombocytopen<br />
ia due to HCVrelated<br />
cirrhosis,<br />
approve to allow<br />
for initiation of<br />
antiviral<br />
therapy.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
promethazine<br />
syrup 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
after consultation<br />
with, either a<br />
gastroenterologist<br />
or a physician who<br />
specializes in<br />
infectious disease.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
173<br />
OTHER<br />
CRITERIA<br />
Approve if the<br />
patient has tried<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,<br />
desloratadine,<br />
levocetirizine,<br />
fexofenadine/ps<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current<br />
condition.<br />
Approve<br />
promethazine
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
diphenhydramin<br />
e (capsules or<br />
elixir) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
insomnia.<br />
Approve<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
174
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
promethazine tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Patients aged less<br />
than 65 years,<br />
approve. Patients<br />
aged 65 years and<br />
older, other criteria<br />
apply.<br />
N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
175<br />
OTHER<br />
CRITERIA<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
Approve if the<br />
patient has tried<br />
a prescription<br />
oral second<br />
generation<br />
antihistamine<br />
product<br />
(cetirizine,<br />
fexofenadine,<br />
desloratadine,<br />
levocetirizine,<br />
fexofenadine/ps
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
eudoephedrine,<br />
or<br />
desloratadine/ps<br />
eudoephedrine)<br />
for the current<br />
condition.<br />
Approve<br />
promethazine<br />
hydrochloride<br />
tablets or syrup<br />
if the patient has<br />
tried a<br />
prescription oral<br />
anti-emetic<br />
agent<br />
(ondansetron,<br />
granisetron,<br />
dolasetron,<br />
palonosetron,<br />
aprepitant) for<br />
the current<br />
condition.<br />
Approve<br />
diphenhydramin<br />
e (capsules or<br />
elixir) if the<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
176
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
PROVIGIL<br />
TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For the FDA-approved<br />
indication of excessive<br />
sleepiness due to<br />
obstructive sleep<br />
AGE<br />
RESTRICTION<br />
ADHD or ADD in<br />
patients less than<br />
18 years.<br />
Adjunctive<br />
PRESCRIBER<br />
RESTRICTION<br />
Idiopathic<br />
hypersomnia must<br />
have the diagnosis<br />
confirmed by a<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
177<br />
OTHER<br />
CRITERIA<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
insomnia.<br />
Approve<br />
hydroxyzine<br />
hydrochloride<br />
(tablets and<br />
syrup) or<br />
hydroxyzine<br />
pamoate<br />
(capsules) if the<br />
patient has tried<br />
at least two<br />
other FDAapproved<br />
products for the<br />
management of<br />
anxiety.<br />
Excessive<br />
sleepiness due<br />
to OSAHS if the<br />
patient has tried
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
excluded from<br />
Part D.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
apnea/hypoapnea<br />
syndrome (OSAHS)<br />
patients must have tried<br />
continuous positive<br />
airway pressure (CPAP).<br />
For the FDA-approved<br />
indication of excessive<br />
sleepiness due to shiftwork<br />
sleep disorder<br />
(SWSD), patients must<br />
be working at least 5<br />
overnight shifts per<br />
month.<br />
AGE<br />
RESTRICTION<br />
augmentation<br />
treatment for<br />
depression must be<br />
in adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
sleep specialist specified.<br />
physician or at an<br />
institution that<br />
specializes in sleep<br />
disorders.<br />
OTHER<br />
CRITERIA<br />
CPAP.<br />
Excessive<br />
sleepiness due<br />
to SWSD if the<br />
patient is<br />
working at least<br />
5 overnight<br />
shifts per month.<br />
ADHD/ADD<br />
who have tried<br />
two alternative<br />
medications for<br />
ADHD/ADD<br />
from two<br />
different classes<br />
as follows:<br />
methylphenidate<br />
products (e.g.<br />
methylphenidate<br />
,<br />
dexmethylpheni<br />
date),<br />
amphetamines<br />
(e.g., mixed<br />
amphetamine<br />
salts,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
178
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
PULMICORT 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
179<br />
OTHER<br />
CRITERIA<br />
dextroamphetam<br />
ine),<br />
atomoxetine,<br />
bupropion or<br />
tricyclic<br />
antidepressants<br />
(TCAs e.g.,<br />
imipramine,<br />
desipramine).<br />
Adjunctive/aug<br />
mentation<br />
treatment for<br />
depression in<br />
adults if the<br />
patient is<br />
concurrently<br />
receiving other<br />
medication<br />
therapy for<br />
depression.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending N/A N/A N/A N/A N/A N/A
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
PULMOZYME<br />
SOLN. 2<br />
RAPAMUNE<br />
SOLN. 2<br />
All FDA<br />
approved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Cystic<br />
Fibrosis N/A N/A N/A N/A<br />
Initial auth for 3<br />
months. May<br />
renew for 3 or 6<br />
months for a Pulmozyme will<br />
total treatment undergo Part B<br />
of 12 months. vs D review.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
180
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
RAPAMUNE<br />
TAB 2<br />
REBIF INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
N/A N/A N/A<br />
Prescribed by or<br />
after consultation<br />
<strong>Authorization</strong><br />
will be for 12<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
181<br />
OTHER<br />
CRITERIA<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
REBIF INJ.,<br />
TITRATION<br />
PAK 2<br />
RECLAST INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Multiple<br />
Sclerosis<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Multiple<br />
Sclerosis N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
with a neurologist<br />
or an MS<br />
specialist.<br />
Prescribed by or<br />
after consultation<br />
with a neurologist<br />
or an MS<br />
specialist.<br />
COVERAGE<br />
DURATION<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
182<br />
OTHER<br />
CRITERIA<br />
N/A<br />
Reclast may be<br />
approved for the<br />
covered<br />
osteoporosis<br />
indications and<br />
osteogenesis<br />
imperfecta, if 1)<br />
the patient has<br />
tried one oral<br />
bisphosphonate<br />
or oral<br />
bisphosphonate-
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
containing<br />
product AND<br />
the patient has<br />
an inadequate<br />
response as<br />
determined by<br />
the prescribing<br />
physician or the<br />
patient has<br />
intolerability to<br />
an oral<br />
bisphosphonate,<br />
or 2) the patient<br />
cannot take an<br />
oral<br />
bisphosphonate<br />
product because<br />
they cannot<br />
swallow, or<br />
because they<br />
cannot remain in<br />
an upright<br />
position post<br />
oral<br />
bisphosphonate<br />
administration,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
183
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
or because the<br />
patient has a<br />
chronic and<br />
complex<br />
existing<br />
medication<br />
regimen in<br />
which an oral<br />
bisphosphonate<br />
agent will likely<br />
compromise<br />
therapy as<br />
determined by<br />
the prescribing<br />
physician, this<br />
exception will<br />
be evaluated by<br />
a pharmacist<br />
and/or physician<br />
on a case-bycase<br />
basis, or<br />
because the<br />
patient has a<br />
pre-existing<br />
gastrointestinal<br />
medical<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
184
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
RECOMBIVAX-<br />
HB INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
185<br />
OTHER<br />
CRITERIA<br />
condition (eg,<br />
esophageal<br />
lesions,<br />
esophageal<br />
ulcers, etc.) in<br />
which<br />
intravenous<br />
bisphosphonate<br />
therapy may be<br />
medically<br />
preferred over<br />
oral therapy.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
REGRANEX<br />
GEL 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
any<br />
granulating<br />
ulcer/wound<br />
(eg, pressure<br />
ulcers, venous<br />
stasis ulcers)<br />
that is<br />
classified as<br />
NPUAP Stage<br />
III or IV. Any<br />
clean and<br />
granulating<br />
ulcer/wound<br />
classified as<br />
NPUAP Stage<br />
II.<br />
N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Diabetic neuropathic<br />
ulcer(s) that is/are<br />
classified as NPUAP<br />
Stage III or IV. Any<br />
clean and granulating<br />
ulcer/wound classified as<br />
Stage II (e.g., Stage II<br />
diabetic neuropathic<br />
ulcers and pressure<br />
ulcers), III or IV. N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
186<br />
OTHER<br />
CRITERIA<br />
Diabetic<br />
neuropathic<br />
ulcer(s) that<br />
is/are classified<br />
as NPUAP<br />
Stage III or IV.<br />
Any granulating<br />
ulcer/wound<br />
classified as<br />
Stage III or IV.<br />
Any clean and<br />
granulating<br />
ulcer/wound<br />
classified as<br />
Stage II (e.g.,<br />
Stage II diabetic<br />
neuropathic<br />
ulcers and<br />
pressure ulcers),<br />
if the patient has<br />
tried other<br />
standard<br />
ulcer/wound<br />
care therapies
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
RELISTOR INJ. 2<br />
REMICADE<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
All FDA<br />
approved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Crohn<br />
disease.<br />
Ankylosing<br />
spondylitis.<br />
Plaque<br />
psoriasis.<br />
Rheumatoid<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
N/A<br />
N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Initial Therapy: Member<br />
must meet all 3 criteria.<br />
1.Opioid-induced<br />
constipation.<br />
2.Advanced illness<br />
receiving palliative care.<br />
3.Failed 2<br />
laxative/bowel therapies. N/A<br />
Rheumatoid Arthritis.<br />
Tried 1 diseasemodifying<br />
antirheumatic<br />
drug for 2 mos or<br />
concurrently receiving<br />
methotrexate (MTX).<br />
Crohn Disease (CD) for<br />
induction of remission<br />
(IR). Tried corticosteroid<br />
(CS) or CSs<br />
contraindicated or if<br />
currently on CS. CD for<br />
AGE<br />
RESTRICTION<br />
Rheumatoid<br />
arthritis (RA) and<br />
SD, Adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
187<br />
N/A<br />
N/A<br />
OTHER<br />
CRITERIA<br />
(eg,<br />
debridement,<br />
topical therapies<br />
[collagenase])<br />
for at least 4<br />
weeks.<br />
Initial=1<br />
kit.Continuation<br />
of therapy<br />
approved for<br />
duration of<br />
contract year<br />
subject to<br />
member elegi N/A<br />
If<br />
contraindication<br />
s to nearly all<br />
other<br />
tx,exceptions to<br />
be evaluated by<br />
CD (w/ or w/out pharmacist<br />
fistulas)=12 wks and/or MD on<br />
for induction of case-by-case<br />
remission basis. Ulcerative<br />
(IR).All other colitis (UC).<br />
conds=12mos. Tried 2-mo trial
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Arthritis.<br />
Still’s disease.<br />
Psoriatic<br />
arthritis.<br />
Ulcerative<br />
colitis. Behcet<br />
syndrome<br />
uveitis. Celiac<br />
sprue.<br />
Erythrodermic<br />
psoriasis.<br />
Giant cell<br />
arteritis. Graft<br />
versus host<br />
disease.<br />
Hidradenitis<br />
suppurativa.<br />
Juvenile<br />
idiopathic<br />
arthritis.<br />
Pustular<br />
psoriasis.<br />
Pyoderma<br />
gangrenosum.<br />
Sarcoidosis.<br />
Uveitis.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
maintenance of<br />
remission (MR). Got 3<br />
infliximab (IFB) doses<br />
and responded, or tried<br />
azathioprine (AZA), 6-<br />
mercaptopurine (6MP),<br />
MTX, adalimumab, or<br />
certolizumab pegol.<br />
Fistulizing CD (FCD)<br />
for IR, approve. FCD for<br />
MR. Got 3 doses of IFB<br />
and responded. Plaque<br />
psoriasis (PP). A<br />
minimum body surface<br />
area (BSA) of 5% or<br />
more, exceptions for less<br />
than 5% BSA if PP of<br />
palms, soles, head/neck,<br />
nails, intertriginous areas<br />
or genitalia or<br />
inadequate response to<br />
2-mo trial of topical<br />
therapy (tx) OR<br />
localized phototx<br />
(ultraviolet B [UVB] or<br />
oral methoxsalen plus<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
of systemic CS,<br />
6-MP, AZA,<br />
CSA or<br />
tacrolimus.<br />
Uveitis.Tried<br />
periocular/intrao<br />
cular CS,<br />
systemic CS,<br />
immunosuppres<br />
sant (eg, MTX,<br />
mycophenolate<br />
mofetil, CSA,<br />
AZA,<br />
cyclophosphami<br />
de), etanercept,<br />
adalimumab.<br />
Pyoderma<br />
gangrenosum<br />
(PG).Tried 1<br />
systemic tx (eg,<br />
systemic CS,<br />
immunosuppres<br />
sant (eg, AZA,<br />
6MP, CSA,<br />
cyclophosphami<br />
de,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
188
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
REMODULIN<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Wegener<br />
granulomatosi<br />
s.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
UVA light [PUVA]),<br />
and inadequate response<br />
to 2-mo trial of systemic<br />
tx (w/ one of-MTX,<br />
cyclosporine (CSA),<br />
acritretin, adalimumab,<br />
alefacept, etanercept, or<br />
ustekinumab) or<br />
contraindications to all,<br />
and significant disability<br />
or impairment in<br />
physical or mental<br />
functioning according to<br />
treating physician<br />
(MD).Tried systemic tx<br />
(MTX, CSA, acritretin,<br />
etanercept, alefacept,<br />
adalimumab, or<br />
ustekinumab) for 2 mos<br />
or phototx (UVB or<br />
PUVA) for 2 mos.<br />
AGE<br />
RESTRICTION<br />
All FDA<br />
approved<br />
indications not<br />
otherwise<br />
excluded from N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Initial=36<br />
weeks.<br />
Continuation of<br />
therapy<br />
approved for<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
189<br />
OTHER<br />
CRITERIA<br />
chlorambucil),<br />
etanercept or<br />
adalimumab) for<br />
2 mos, or 2-mo<br />
trial of<br />
intralesional CS<br />
or CSA for<br />
localized PG.<br />
Graft versus<br />
host disease<br />
(GVHD).Tried 1<br />
tx (eg, high-dose<br />
CS,<br />
antithymocyte<br />
globulin, CSA,<br />
thalidomide,<br />
tacrolimus,<br />
mycophenolate<br />
mofetil, etc.) or<br />
receiving IFB<br />
concurrently.<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
REVATIO TAB 2<br />
RITUXAN INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Part D.<br />
Pulmonary<br />
arterial<br />
hypertension<br />
(WHO Class<br />
I) with NYHA<br />
Class II, III or<br />
IV symptoms.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For initial approval for<br />
use in pulmonary arterial<br />
hypertension (PAH),<br />
approve if patient has<br />
had a right-heart<br />
catheterization to<br />
confirm diagnosis of<br />
PAH to ensure<br />
appropriate medical<br />
assessment. For patients<br />
currently receiving<br />
sildenafil or tadalafil,<br />
approve if patient has a<br />
diagnosis of PAH. N/A<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise N/A N/A RA, adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
duration of<br />
contract year.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
190<br />
OTHER<br />
CRITERIA<br />
For PAH, if <strong>Authorization</strong><br />
prescribed by, or in will be for 12<br />
consultation with, a months, unless<br />
cardiologist or a<br />
pulmonologist.<br />
otherwise<br />
specified. N/A<br />
Adult with RA RA.Approve 2 Adult with RA<br />
(initial and repeat doses.16 wks or (initial course),<br />
courses). more after, approve if<br />
Prescribed by a approve 2 more patient has tried
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
excluded from<br />
Part D. All<br />
medicallyaccepted<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Patients<br />
already started<br />
on Rituxan for<br />
rheumatoid<br />
arthritis (RA).<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
rheumatologist or<br />
in consultation<br />
with a<br />
rheumatologist.<br />
Non-RA<br />
indications, if<br />
prescribed by or in<br />
consultation with<br />
an oncologist,<br />
hematologist,<br />
neurologist,<br />
multiple sclerosis<br />
(MS) specialist,<br />
rheumatologist,<br />
dermatologist, or<br />
immunologist, or<br />
who are being<br />
managed by a<br />
transplant center.<br />
COVERAGE<br />
DURATION<br />
doses if<br />
response per<br />
doctor.Othr=12<br />
mos.<br />
OTHER<br />
CRITERIA<br />
at least 1 of the<br />
following<br />
biologic<br />
DMARDs,<br />
etanercept,<br />
certolizumab<br />
pegol,<br />
golimumab,<br />
infliximab, or<br />
adalimumab, for<br />
at least 2<br />
months. Adult<br />
with RA (repeat<br />
course), approve<br />
if 16 weeks or<br />
more after the<br />
first dose of the<br />
previous<br />
rituximab<br />
regimen and the<br />
patient has<br />
responded (eg,<br />
less joint pain,<br />
morning<br />
stiffness, or<br />
fatigue, or<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
191
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
sildenafil tab 1<br />
SIMPONI 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
All FDAapproved<br />
N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For initial approval for<br />
use in pulmonary arterial<br />
hypertension (PAH),<br />
approve if patient has<br />
had a right-heart<br />
catheterization to<br />
confirm diagnosis of<br />
PAH to ensure<br />
appropriate medical<br />
assessment. For patients<br />
currently receiving<br />
sildenafil or tadalafil,<br />
approve if patient has a<br />
diagnosis of PAH. N/A<br />
AGE<br />
RESTRICTION<br />
For moderate to severe<br />
RA intolerance to or N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
192<br />
OTHER<br />
CRITERIA<br />
improved<br />
mobility, or<br />
decreased soft<br />
tissue swelling<br />
in joints or<br />
tendon sheaths)<br />
as determined<br />
by the<br />
prescribing<br />
physician.<br />
For PAH, if <strong>Authorization</strong><br />
prescribed by, or in will be for 12<br />
consultation with, a months, unless<br />
cardiologist or a<br />
pulmonologist.<br />
otherwise<br />
specified. N/A<br />
Approved For members<br />
through duration with a diagnosis
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
SIMULECT<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
failure of therapy with<br />
methotrexate (greater<br />
than 20mg/wk) and 1<br />
DMARD and Enbrel.<br />
Peripheral Ankylosing<br />
Spondylitis or Psoriatic<br />
Arthritis requires failure<br />
of 1 DMARD and<br />
Enbrel.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
193<br />
OTHER<br />
CRITERIA<br />
of early, severeonset<br />
RA,<br />
additional<br />
required medical<br />
information is<br />
not required.<br />
Members with<br />
Axial<br />
Ankylosing<br />
Spondylitis, no<br />
other medical<br />
information is<br />
required.
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
SOMATULINE<br />
DEPOT INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
OTHER<br />
CRITERIA<br />
SPORANOX<br />
SOLN. 2<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Tinea N/A<br />
Onychomycosis must be<br />
judged to be medically<br />
significant (causing<br />
impaired mobility,<br />
discomfort, or in the<br />
presence of diabetes N/A N/A<br />
Ony=12wks<br />
toenails,8wks<br />
fingernails.Cand<br />
ida ony,4<br />
mos.Other<br />
conds=12mos.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
194<br />
Tinea corporis<br />
after a trial of a<br />
topical<br />
antifungal agent,<br />
except for<br />
extensive
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
corporis.<br />
Tinea cruris,<br />
faciei,<br />
manuum,<br />
imbricata, and<br />
pedis<br />
(nonmoccasin<br />
or chronic<br />
type). Plantaror<br />
moccasintype<br />
dry tinea<br />
pedis. Tinea or<br />
pityriasis<br />
versicolor.<br />
Tinea capitis.<br />
Tinea barbae.<br />
Treatment of<br />
vaginal<br />
candidiasis.<br />
Prevention of<br />
recurrent<br />
vulvovaginal<br />
or vaginal<br />
candidiasis.<br />
Treatment or<br />
prevention of<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
mellitus, an<br />
immunocompromised<br />
condition) by the<br />
treating physician and a<br />
positive KOH, fungal<br />
culture, DTM culture,<br />
nail biopsy, or histologic<br />
examination (PAS) is<br />
required before therapy<br />
initiation. Before a<br />
second course of<br />
treatment is permitted<br />
for onychomycosis, a<br />
culture must demonstrate<br />
a fungal infection. Use<br />
of topical ciclopirox 8%<br />
solution with<br />
itraconazole is not<br />
permitted. Itraconazole<br />
should not be given for<br />
the treatment of<br />
onychomycosis in<br />
patients with CHF.<br />
Itraconazole is permitted<br />
for the treatment of<br />
patients with Candida<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
conditions.<br />
Tinea cruris,<br />
faciei, manuum,<br />
imbricata, and<br />
pedis<br />
(nonmoccasin or<br />
chronic type)<br />
after a trial of a<br />
topical<br />
antifungal agent.<br />
Tinea or<br />
pityriasis<br />
versicolor after<br />
trial of a topical<br />
antifungal agent,<br />
except for<br />
extensive<br />
conditions.<br />
Treatment of<br />
vaginal<br />
candidasis after<br />
a trial of oral<br />
fluconazole.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
195
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
SPRYCEL TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
other<br />
superficial,<br />
systemic or<br />
suspected<br />
fungal<br />
infections.<br />
Patient has<br />
been started<br />
and stabilized<br />
on intravenous<br />
(IV)<br />
itraconazole<br />
therapy or oral<br />
itraconazole<br />
for a systemic<br />
infection and<br />
it is being<br />
used as<br />
continuation<br />
therapy.<br />
Candida<br />
onychomycosi<br />
s.<br />
All medicallyaccepted<br />
indications not N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
onychomycosis if they<br />
have a culture positive<br />
for Candida.<br />
Diagnosis for which<br />
Sprycel is being used.<br />
For indications of CML N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
196<br />
N/A<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
OTHER<br />
CRITERIA<br />
For CML, new<br />
patient must<br />
have Ph-positive
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
STREPTOMYCI<br />
N INJ. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
otherwise<br />
excluded from<br />
Part D.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
and ALL, the<br />
Philadelphia<br />
chromosome (Ph) status<br />
of the leukemia must be<br />
reported. New patients<br />
with CML and ALL<br />
which is Ph-positive<br />
may receive<br />
authorization for<br />
Sprycel.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
197<br />
OTHER<br />
CRITERIA<br />
CML for<br />
approval of<br />
Sprycel. For<br />
ALL, new<br />
patient must<br />
have Ph-positive<br />
ALL for<br />
approval of<br />
Sprycel.
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
SUBOXONE SL<br />
FILM 2<br />
SUBOXONE SL<br />
TAB 2<br />
SUTENT CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
Renal Cell Carcinoma<br />
and Gastrointestinal<br />
Stromal Tumor in a Sutent requires the<br />
patient who has tried and patient to be at<br />
failed Gleevec. least 18 years old.<br />
PRESCRIBER<br />
RESTRICTION<br />
Sutent requires the<br />
prescriber to be an<br />
Oncologist or<br />
under the direct<br />
consultation of an<br />
Oncologist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
OTHER<br />
CRITERIA<br />
N/A<br />
N/A<br />
N/A<br />
SYMBICORT<br />
INHALER 2<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from N/A N/A N/A N/A<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
198<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
tacrolimus cap 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Part D. Plus<br />
COPD.<br />
Chronic<br />
bronchitis.<br />
Emphysema.<br />
Postinfectious<br />
cough (ie,<br />
cough<br />
persisting after<br />
an acute<br />
respiratory<br />
infection has<br />
resolved).<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
199<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TASIGNA CAP 2<br />
TAXOTERE<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
of the drug to<br />
make the<br />
determination.<br />
All medicallyaccepted<br />
indications not<br />
otherwise<br />
excluded from<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Diagnosis for which<br />
Tasigna is being used.<br />
For indication of CML,<br />
the Philadelphia<br />
chromosome (Ph) status<br />
of the leukemia must be<br />
reported. New patients<br />
with CML which is Phpositive<br />
may receive<br />
authorization for<br />
Tasigna. N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
Part D. N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
200<br />
OTHER<br />
CRITERIA<br />
For CML, new<br />
patient must<br />
have Ph-positive<br />
CML for<br />
approval of<br />
Tasigna.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
terbinafine tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Tinea<br />
corporis.<br />
Tinea cruris,<br />
faciei,<br />
manuum,<br />
pedis, and<br />
imbricate.<br />
Plantar- or<br />
moccasin-type<br />
dry tinea<br />
pedis. Black<br />
piedra. Tinea<br />
capitis. Tinea<br />
barbae.<br />
Cutaneous<br />
(skin)<br />
candidiasis. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Onychomycosis must be<br />
judged to be medically<br />
significant (causing<br />
impaired mobility,<br />
discomfort, or in the<br />
presence of diabetes<br />
mellitus, an<br />
immunocompromised<br />
condition) by the<br />
treating physician and a<br />
positive KOH, fungal<br />
culture, DTM culture,<br />
nail biopsy, or histologic<br />
examination (PAS) is<br />
required before therapy<br />
initiation. Before a<br />
second course of<br />
treatment is permitted<br />
for onychomycosis, a<br />
culture must demonstrate<br />
a fungal infection. Use<br />
of topical ciclopirox 8% N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
201<br />
N/A<br />
Ony=6wks<br />
fingernails, 12<br />
wks<br />
toenails.Other<br />
conds=12mos.<br />
OTHER<br />
CRITERIA<br />
Tinea corporis if<br />
the patient has<br />
trial a topical<br />
antifungal agent,<br />
except for<br />
extensive<br />
conditions.<br />
Tinea cruris,<br />
faciei, manuum,<br />
pedis, and<br />
imbricate after a<br />
trial of a topical<br />
antifungal agent.<br />
Cutaneous<br />
(skin)<br />
candidiasis after<br />
a trial of a<br />
topical<br />
antifungal agent<br />
and an oral<br />
azole antifungal.<br />
Other superficial
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TESTIM GEL 2<br />
TETANUS/<br />
DIPHTHERIA<br />
TOXOID INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Other<br />
superficial<br />
fungal skin<br />
infections.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
solution with terbinafine<br />
is not permitted.<br />
AGE<br />
RESTRICTION<br />
Two morning<br />
testosterone levels fall<br />
below the normal range<br />
for a healthy adult male.<br />
Patient must have tried<br />
and failed<br />
ANDRODERM and<br />
ANDROGEL N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
Part D. N/A<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
202<br />
OTHER<br />
CRITERIA<br />
fungal skin<br />
infections after a<br />
trial of a topical<br />
antifungal agent<br />
or an oral<br />
antifungal agent.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TEV-TROPIN<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
Use in the<br />
management of<br />
acute critical<br />
illness due to<br />
complications of<br />
surgery, trauma,<br />
or with acute<br />
respiratory<br />
failure, as<br />
antiaging<br />
therapy, to<br />
improve<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Child/adolesc<br />
documented GH stim<br />
test (levodopa, insulininduced<br />
hypoglycemia,<br />
arginine, clonidine,<br />
glucagon) w/GH<br />
response less than 10<br />
ng/mL AND baseline<br />
height (Ht) less than the<br />
3rd percentile (pct) for<br />
gender/age AND pretx<br />
Ht growth rate (GR)<br />
functional status child less than 3 yrs of<br />
in elderly, less than 7 cm/yr and<br />
somatopause, child greater than or<br />
enhancement of equal to 3 yrs of less<br />
athletic ability, than 4 cm/yr OR child<br />
bone marrow any age GR less than the<br />
transplant 10th pct for age/gender<br />
(BMT) without based on min 6 mos of<br />
total body data.Child w/brain<br />
irradiation, bony radiation does not have<br />
AGE<br />
RESTRICTION<br />
TS, children.<br />
SHOX/CRI/NS,<br />
children/adolescent<br />
s. SGA, 2 to 8 yrs.<br />
HIV failure to<br />
thrive, less than 17<br />
yrs. SBS/HIV<br />
cachexia/wasting,<br />
adults.<br />
PRESCRIBER<br />
RESTRICTION<br />
For adults, the<br />
endocrinologist<br />
must certify that<br />
the somatropin is<br />
not being<br />
prescribed for antiaging<br />
therapy or to<br />
enhance athletic<br />
ability.<br />
Child/adolesc must<br />
be evalaluated by<br />
pediatric<br />
endocrinologist<br />
COVERAGE<br />
DURATION<br />
GH DF 12<br />
mos.SBS 4<br />
wks/yr.Non-GH<br />
DF ISS 6<br />
mos.HIV<br />
wast/cach 24<br />
wks.HIV failure<br />
to thrive 12 wks.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
203<br />
OTHER<br />
CRITERIA<br />
Adult GH DF<br />
(start),<br />
document<br />
diagnosis of GH<br />
DF due to adultonset<br />
(GH alone<br />
or multiple<br />
hormone<br />
deficiencies/hyp<br />
opituitarism<br />
from pituitary<br />
dz,<br />
hypothalamic<br />
dz, surgery,<br />
cranial radiation<br />
tx, tumor<br />
txment,<br />
traumatic brain<br />
injury, or<br />
subarachnoid<br />
hemorrhage) or<br />
due to
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
dysplasias, burn<br />
injury, cardiac<br />
transplantation,<br />
central<br />
precocius<br />
puberty, chronic<br />
fatigue<br />
syndrome,<br />
congenital<br />
adrenal<br />
hyperplasia,<br />
constitutional<br />
delay of growth<br />
and puberty,<br />
corticosteroidinduced<br />
short<br />
stature including<br />
a variety of<br />
chronic<br />
glucocorticoiddependent<br />
conditions, such<br />
as asthma,<br />
juvenile<br />
rheumatoid<br />
arthritis, after<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
to meet baseline Ht<br />
crit.Congenital<br />
hypopituitarism does not<br />
have to meet Ht or GR<br />
crit.Child<br />
w/hypophysectomy,<br />
approve.Child/adolesc<br />
GH DF cont tx, GR<br />
increased by 2.5 cm/yr<br />
or more in most recent<br />
yr (MRY) per MD AND<br />
epiphyses open (older<br />
than 12 yrs), both crit<br />
exclude adolesc<br />
w/hypopituitarism.Revie<br />
w GR annually (not<br />
applied to<br />
hypopituitarism).Adoles/<br />
yng adult w/completed<br />
linear growth (GR less<br />
than 2 cm/yr), review for<br />
adult GH DF.Greater<br />
than 18 yrs, auth not<br />
allowed if midparental ht<br />
attained.ISS child<br />
w/open epiphyses,6 mo<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
childhood-onset<br />
(GH not rec in<br />
adults who had<br />
GH tx as child<br />
for uses not due<br />
to GH DF) AND<br />
negative<br />
response to 1<br />
GH stim test<br />
(insulin<br />
tolerance [peak<br />
less than 5<br />
mcg/L], or<br />
glucagon [peak<br />
less than 3<br />
mcg/L]) [GHRH<br />
plus arginine<br />
may be used if<br />
available]<br />
(exclude stim<br />
test for<br />
childhood-onset<br />
due to<br />
mutations,<br />
lesions,<br />
congenital<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
204
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
renal, heart,<br />
liver, or BMT,<br />
Crohn's disease,<br />
cystic fibrosis,<br />
dilated<br />
cardiomyopathy<br />
/heart failure,<br />
end-stage renal<br />
disease in adults<br />
undergoing<br />
hemodialysis,<br />
Down's<br />
syndrome,<br />
familial<br />
dysautonomia,<br />
fibromyalgia,<br />
HIV-infected<br />
patients with<br />
alterations in<br />
body fat<br />
distribution,<br />
infertility,<br />
kidney<br />
transplant<br />
patients<br />
(children) with a<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
trial if baseline Ht less<br />
than 3rd pct (greater than<br />
2 SD below mean for<br />
gender/age) AND pretx<br />
GR child less than 3 yrs<br />
of less than 7 cm/yr and<br />
child greater than or<br />
equal to 3 yrs of less<br />
than 4 cm/yr OR child<br />
any age GR less than the<br />
10th pct for age/gender<br />
based on min 6 mos of<br />
data AND PE certifies<br />
child's basic activities of<br />
daily living limited by<br />
SS and has condition<br />
which GH is/may be<br />
effective AND PE<br />
certifies via bone-age x-<br />
ray, predicted adult Ht<br />
less than 3rd pct.Auth<br />
after initial tx (auth for<br />
12 mos) based on<br />
adequate clinical<br />
response (annualized GR<br />
doubles).Cont tx (after<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
defects),<br />
transition adoles<br />
off somatropin 1<br />
mo before<br />
retesting, OR 3<br />
or more<br />
pituitary<br />
hormone<br />
deficiencies<br />
(TSH, ACTH,<br />
LH/FSH, or<br />
AVP) AND<br />
serum IGF-1 84<br />
microg/L or less<br />
using the<br />
Esoterix ECB<br />
RIA or<br />
age/gender<br />
adjusted serum<br />
IGF-1 SDS<br />
below the 2.5<br />
percentile.TS<br />
start, female and<br />
has short stature<br />
(SS).SHOX<br />
start, open<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
205
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
functional renal 12 to 18 mos), GR<br />
allograft, liver increased by 2.5 cm/yr<br />
transplantation, or more in MRY per MD<br />
multiple system AND epiphyses open<br />
atrophy, (older than 12<br />
myelomeningoc yrs).Greater than 18 yrs,<br />
ele, obesity, auth not allowed if<br />
osteogenesis midparental ht attained.<br />
imperfecta,<br />
osteoporosis<br />
(postmenopausa<br />
l, idiopathic in<br />
men,<br />
glucocorticoidinduced),<br />
thalassemia, and<br />
X-linked<br />
hypophosphate<br />
mic rickets<br />
(familial<br />
hypophosphate<br />
mia,<br />
hypophosphate<br />
mic rickets).<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
epiphyses.CRI<br />
w/growth failure<br />
(GF), start,<br />
approve.Child<br />
PW w/GF or<br />
adult PW,<br />
approve.NS<br />
start, baseline ht<br />
less than 3rd<br />
percentile.TS/S<br />
HOX/CRI/child<br />
PW/NS, cont tx,<br />
GR increased by<br />
2.5 cm/yr or<br />
more in most<br />
recent yr (MRY)<br />
AND epiphyses<br />
open.SGA/IUG<br />
R start, born<br />
SGA AND no<br />
sufficient catchup<br />
growth<br />
before age 4 yr,<br />
AND age 2 to 8<br />
yrs, if older than<br />
8 yrs, approve 1<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
206
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
yr trial if<br />
prepubertal,<br />
AND baseline ht<br />
less than 3rd<br />
percentile for<br />
gender/age.Cont<br />
tx, GR increased<br />
by 2.5 cm/yr or<br />
more in most<br />
recent, if aged 2<br />
to 8 yrs, or by 3<br />
or more cm/yr if<br />
older than 8 yrs<br />
and<br />
prepubertal.HIV<br />
w/wasting or<br />
cachexia, HIVpositive<br />
AND<br />
have 1 of the<br />
following,<br />
documented<br />
unintentional wt<br />
loss of greater<br />
than or equal to<br />
10% from<br />
baseline OR wt<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
207
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
less than 90% of<br />
the lower limit<br />
of ideal body wt<br />
OR BMI less<br />
than or equal to<br />
20 kg/m2 AND<br />
able to consume<br />
or be fed via<br />
parenteral or<br />
enteral feedings<br />
75% or more of<br />
maintenance<br />
energy<br />
requirements<br />
based on current<br />
body weight<br />
AND on<br />
antiretroviral tx<br />
greater than or<br />
equal to 30 days<br />
prior to<br />
beginning GH tx<br />
and will<br />
continue<br />
antiretroviral tx<br />
throughout GH<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
208
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
txment. Repeat<br />
12 or 24-wk<br />
courses of GH<br />
may be<br />
authorized after<br />
initial 12 or 24-<br />
wk GH course<br />
for HIV<br />
infection<br />
w/wasting or<br />
cachexia<br />
provided that<br />
they are off GH<br />
for at least 1 mo<br />
and meet all of<br />
previous HIV<br />
criteria.HIVassoc<br />
failure to<br />
thrive.Able to<br />
consume or be<br />
fed via<br />
parenteral or<br />
enteral feedings<br />
75% or more of<br />
maintenance<br />
energy<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
209
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
THIOTEPA INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
210<br />
OTHER<br />
CRITERIA<br />
requirements<br />
based on current<br />
body wt AND<br />
on antiretroviral<br />
tx for greater<br />
than or equal to<br />
30 days prior to<br />
beginning GH tx<br />
and will<br />
continue<br />
antiretroviral<br />
tx.SBS,<br />
receiving<br />
specialized<br />
nutritional<br />
support.SBS pts<br />
eval on case-bycase<br />
basis for<br />
more than one<br />
4-wk course per<br />
yr.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TOBI NEB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
211<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
topiramate<br />
sprinkle cap 1<br />
topiramate tab 1<br />
toposar inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
determination.<br />
All FDAapproved<br />
<strong>Authorization</strong><br />
indications not<br />
will be for 12<br />
otherwise<br />
months, unless<br />
excluded from<br />
otherwise<br />
Part D. N/A N/A N/A N/A<br />
specified. N/A<br />
All FDAapproved<br />
<strong>Authorization</strong><br />
indications not<br />
will be for 12<br />
otherwise<br />
months, unless<br />
excluded from<br />
otherwise<br />
Part D. N/A N/A N/A N/A<br />
specified. N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
212<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
topotecan inj. 1<br />
TORISEL<br />
SOLN 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
213<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TRACLEER<br />
TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Patients<br />
currently on<br />
Letairis or<br />
Tracleer for<br />
treatment of<br />
pulmonary<br />
arterial<br />
hypertension. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
For the FDA-approved<br />
indication of pulmonary<br />
arterial hypertension,<br />
patients not currently on<br />
Letairis or Tracleer are<br />
required to have had a<br />
right-heart<br />
catheterization to<br />
confirm the diagnosis of<br />
PAH to ensure<br />
appropriate medical<br />
assessment. For the<br />
FDA-approved<br />
indication of pulmonary<br />
arterial hypertension,<br />
patients currently on<br />
Letairis or Tracleer may N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
For treatment of<br />
pulmonary arterial<br />
hypertension,<br />
Letairis or Tracleer<br />
must be prescribed<br />
by or in<br />
consultation with a<br />
cardiologist or a<br />
pulmonologist.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
214<br />
OTHER<br />
CRITERIA<br />
Digital ulcers,<br />
approve<br />
Tracleer if the<br />
patient has tried<br />
two other<br />
therapies for this<br />
condition such<br />
as calcium<br />
channel blockers<br />
(eg, amlodipine,<br />
felodipine,<br />
isradipine,<br />
nifedipine),<br />
alpha-adrenergic<br />
blockers (eg,<br />
prazosin),<br />
nitroglycerin,
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TRAVASOL<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
continue therapy if they<br />
have a diagnosis of<br />
PAH.<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
215<br />
OTHER<br />
CRITERIA<br />
phosphodiestera<br />
se-5 inhibitors<br />
(eg, sildenafil,<br />
vardenafil), or<br />
angiotensinconverting<br />
enzyme<br />
inhibitors (ACE<br />
inhibitors), or<br />
the patient has<br />
tried one<br />
vasodilator<br />
product (eg,<br />
intravenous<br />
epoprostenol,<br />
intravenous<br />
alprostadil).
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TREANDA INJ 2<br />
tretinoin cream 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not N/A N/A N/A N/A<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
216<br />
OTHER<br />
CRITERIA<br />
For topical<br />
tretinoin<br />
products
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
otherwise<br />
excluded from<br />
Part D.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
otherwise noted. (examples<br />
include Atralin,<br />
Avita, Retin-A,<br />
Retin-A Micro,<br />
Tretin-X, and<br />
generic topical<br />
tretinoin),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
sebaceous<br />
hyperplasia/cyst,<br />
basal cell<br />
carcinoma [skin<br />
cancer],<br />
confluent and<br />
reticulated<br />
papillomatosis)<br />
can be made if<br />
the patient has<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
217
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
tried at least 1<br />
other therapy.<br />
For topical<br />
adapalene<br />
products<br />
(examples<br />
include Differin<br />
gel, Differin<br />
cream, etc. and<br />
generic<br />
adapalene<br />
products),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
sebaceous<br />
hyperplasia/cyst,<br />
basal cell<br />
carcinoma [skin<br />
cancer],<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
218
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
confluent and<br />
reticulated<br />
papillomatosis,<br />
Darier's disease,<br />
molluscum<br />
contagiosum)<br />
can be made if<br />
the patient has<br />
tried at least 1<br />
other therapy.<br />
Coverage of the<br />
combination<br />
clindamycin<br />
plus tretinoin<br />
product (Ziana)<br />
and the<br />
combination<br />
adapalene plus<br />
benzoyl<br />
peroxide<br />
product<br />
(Epiduo) is<br />
recommended<br />
for acne vulgaris<br />
ONLY and all<br />
other indications<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
219
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
tretinoin gel 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
220<br />
OTHER<br />
CRITERIA<br />
are not<br />
recommended.<br />
For topical<br />
tretinoin<br />
products<br />
(examples<br />
include Atralin,<br />
Avita, Retin-A,<br />
Retin-A Micro,<br />
Tretin-X, and<br />
generic topical<br />
tretinoin),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
sebaceous<br />
<strong>Authorization</strong> hyperplasia/cyst,<br />
will be for 12 basal cell<br />
months, unless carcinoma [skin<br />
otherwise noted. cancer],
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
confluent and<br />
reticulated<br />
papillomatosis)<br />
can be made if<br />
the patient has<br />
tried at least 1<br />
other therapy.<br />
For topical<br />
adapalene<br />
products<br />
(examples<br />
include Differin<br />
gel, Differin<br />
cream, etc. and<br />
generic<br />
adapalene<br />
products),<br />
approval for the<br />
treatment of<br />
other noncosmetic<br />
conditions (eg,<br />
dermatitis/ecze<br />
ma, folliculitis,<br />
milia, keratosis<br />
pilaris,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
221
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
sebaceous<br />
hyperplasia/cyst,<br />
basal cell<br />
carcinoma [skin<br />
cancer],<br />
confluent and<br />
reticulated<br />
papillomatosis,<br />
Darier's disease,<br />
molluscum<br />
contagiosum)<br />
can be made if<br />
the patient has<br />
tried at least 1<br />
other therapy.<br />
Coverage of the<br />
combination<br />
clindamycin<br />
plus tretinoin<br />
product (Ziana)<br />
and the<br />
combination<br />
adapalene plus<br />
benzoyl<br />
peroxide<br />
product<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
222
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TRISENOX<br />
INJ. 2<br />
TROPHAMINE<br />
INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
223<br />
OTHER<br />
CRITERIA<br />
(Epiduo) is<br />
recommended<br />
for acne vulgaris<br />
ONLY and all<br />
other indications<br />
are not<br />
recommended.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under N/A N/A N/A N/A N/A N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TYKERB TAB 2<br />
TYSABRI INJ 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All medicallyaccepted<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
All FDA<br />
approved<br />
indications not<br />
otherwise N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Diagnosis for which<br />
Tykerb is being used.<br />
For indication of breast<br />
cancer, the HER2 status<br />
must be reported. New<br />
patients with breast<br />
cancer which is HER2-<br />
positive may receive<br />
authorization for Tykerb. N/A<br />
Adults with MS. Patient<br />
has a relapsing form of<br />
MS. Adults with CD.<br />
Patient has moderately Adults<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
N/A<br />
MS. Prescribed by<br />
a neurologist or an<br />
MS specialist<br />
registered with the<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
224<br />
OTHER<br />
CRITERIA<br />
For breast<br />
cancer, new<br />
patient must<br />
have HER2-<br />
positive breast<br />
cancer for<br />
approval of<br />
Tykerb.<br />
Adults with MS.<br />
Patient has a<br />
relapsing form<br />
of MS and has
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
excluded from<br />
Part D.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
to severely active CD<br />
with evidence of<br />
inflammation (eg,<br />
elevated C-reactive<br />
protein).<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
TOUCH<br />
prescribing<br />
program. CD.<br />
Prescribed by a<br />
physician<br />
registered with the<br />
TOUCH program.<br />
COVERAGE<br />
DURATION<br />
specified.<br />
OTHER<br />
CRITERIA<br />
had an<br />
inadequate<br />
response to, or<br />
is unable to<br />
tolerate, therapy<br />
with at least two<br />
of the following<br />
MS<br />
medications:<br />
interferon beta-<br />
1a (Avonex,<br />
Rebif),<br />
interferon beta-<br />
1b (Betaseron,<br />
Extavia),<br />
glatiramer<br />
acetate<br />
(Copaxone), or<br />
fingolimod<br />
(Gilenya).<br />
Exceptions to<br />
having tried an<br />
interferon beta-<br />
1a or -1b<br />
product<br />
(Avonex,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
225
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
Betaseron,<br />
Extavia, or<br />
Rebif) can be<br />
made if the<br />
patient has<br />
depression or a<br />
mood disorder.<br />
In these cases,<br />
the patient<br />
should try<br />
glatiramer<br />
acetate<br />
(Copaxone) or<br />
fingolimod<br />
(Gilenya), but is<br />
not required to<br />
try an interferon<br />
beta-1a or -1b.<br />
Adults with CD.<br />
Patient has<br />
moderately to<br />
severely active<br />
CD with<br />
evidence of<br />
inflammation<br />
(eg, elevated C-<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
226
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
reactive protein)<br />
and has had an<br />
inadequate<br />
response to<br />
treatment with<br />
corticosteroids<br />
(systemic),<br />
azathioprine, 6-<br />
mercaptopurine,<br />
or methotrexate,<br />
and patient has<br />
tried two TNF<br />
antagonists for<br />
CD for at least 2<br />
months each,<br />
adalimumab,<br />
certolizumab<br />
pegol, or<br />
infliximab, and<br />
had an<br />
inadequate<br />
response or was<br />
intolerant to the<br />
TNF<br />
antagonists.<br />
Exception to the<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
227
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
TYZEKA TAB 2<br />
UVADEX<br />
SOLN 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Requires failure of<br />
Hepsera, Baraclude or<br />
Viread. N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
N/A<br />
This drug may<br />
be covered<br />
under N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
228<br />
OTHER<br />
CRITERIA<br />
CD criteria of<br />
treatment with<br />
corticosteroids<br />
(systemic) are<br />
allowed if<br />
steroids are<br />
contraindicated<br />
or not desired,<br />
then<br />
azathioprine, 6-<br />
mercaptopurine,<br />
or methotrexate<br />
must be tried if<br />
they are not<br />
contraindicated.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
vancomycin inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
229<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
VECTIBIX INJ 2<br />
VENTAVIS<br />
SOLN. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
230<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
VFEND SUSP. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D worded<br />
as invasive<br />
aspergillosis,<br />
esophageal<br />
candidiasis,<br />
treatment of<br />
fungal<br />
infections<br />
caused by<br />
Scedosporium<br />
apiospermum<br />
and Fusarium N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Esophageal candidasis<br />
requires a trial of one<br />
other systemic agent<br />
(eg., fluconazole, IV<br />
amphotericin B,<br />
itraconazole). N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
231<br />
OTHER<br />
CRITERIA<br />
For safety<br />
reasons, if there<br />
is insufficient<br />
information<br />
available to<br />
make a<br />
determination<br />
regarding<br />
coverage and<br />
the prescribing<br />
physician or<br />
representative of<br />
the physician<br />
cannot be<br />
contacted, then<br />
approve 14-day<br />
course.
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
spp., and<br />
treatment of<br />
candidemia in<br />
nonneutropeni<br />
c patients and<br />
the following<br />
Candida<br />
infections:<br />
disseminated<br />
infections in<br />
skin and<br />
infections in<br />
the abdomen,<br />
kidney,<br />
bladder wall,<br />
and wounds,<br />
treatment/prev<br />
ention of other<br />
serious<br />
systemic or<br />
suspected<br />
systemic<br />
fungal<br />
infections.<br />
Continuation<br />
therapy for<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
232
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
VICTOZA INJ. 2<br />
VICTRELIS<br />
CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
patients<br />
started/stabiliz<br />
ed on<br />
intravenous<br />
(IV) or oral<br />
voriconazole<br />
for a systemic<br />
infection.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Part D. N/A N/A N/A N/A<br />
All FDAapprovenanve<br />
HCV RNA titers.Tx-<br />
pts with chronic<br />
indications not<br />
HCV-1 monoinfection<br />
otherwise<br />
without cirrhosis and<br />
excluded from<br />
retx of pts with chronic<br />
Part D. Plus<br />
HCV-1 monoinfection<br />
adult patients<br />
who have been<br />
with Hepatitis<br />
previously treated with<br />
B virus<br />
interferon/peginterferon<br />
(HBV)/chroni<br />
alfa without<br />
c HCV<br />
cirrhosis,greater or equal<br />
genotype 1 co-N/A<br />
to 1 log10 reduction in Adults<br />
PRESCRIBER<br />
RESTRICTION<br />
All FDA-approved<br />
indications.<br />
Prescribed by or in<br />
consultation with a<br />
gastroenterologist<br />
or infectious<br />
disease physician.<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
FDA-approved<br />
indications,auth<br />
orization=8wks<br />
withTW 12, 24<br />
assessment.Othr<br />
=12mo.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
233<br />
OTHER<br />
CRITERIA<br />
N/A<br />
HCV RNA titers<br />
not available but<br />
sent approve<br />
until available.<br />
For all FDAapproved<br />
indications,<br />
patient must<br />
have completed<br />
or will be<br />
completing a 4-<br />
week lead-in
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
infection. HCV RNA at TW 4<br />
required,TW 12 if HCV<br />
RNA less than 100=addl<br />
12wks if HCV RNA<br />
greater or equal to<br />
100=no addl,TW 24 if<br />
early responder with<br />
undetectable HCV RNA<br />
and pt non-black and for<br />
tx-naive pt with chronic<br />
HCV-1 monoinfection<br />
without cirrhosis=addl<br />
4wks,TW 24 if early<br />
responder with<br />
undetectable HCV RNA<br />
and pt non-black and for<br />
retx in pt with chronic<br />
HCV-1 monoinfection<br />
previously treated for<br />
HCV with<br />
interferon/peginterferon<br />
alfa without<br />
cirrhosis=addl<br />
12wks,TW 24 if early<br />
responder with<br />
undetectable HCV RNA<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
with<br />
peginterferon<br />
alfa and<br />
ribavirin prior to<br />
initiating<br />
boceprevir and<br />
boceprevir must<br />
be prescribed in<br />
combination as<br />
triple-drug<br />
therapy with<br />
peginterferon<br />
alfa and<br />
ribavirin.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
234
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
and pt black=addl<br />
24wks,TW 24 if late<br />
responder with<br />
undetectable HCV RNA<br />
and pt non-black=addl<br />
12wks if pt black=addl<br />
24wks,TW 24 if early or<br />
late responder with<br />
detectable HCV<br />
RNA=no addl. Retx in<br />
pts with chronic HCV-1<br />
monoinfection<br />
previously treated with<br />
interferon/peginterferon<br />
alfa without cirrhosis<br />
null-responder<br />
documentation<br />
required,TW 12 if HCV<br />
RNA less than 100=addl<br />
12wks if HCV RNA<br />
greater or equal to<br />
100=no addl,TW 24 if<br />
HCV RNA<br />
undetectable=addl<br />
24wks if HCV RNA<br />
detectable=no addl. Poor<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
235
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
interferon response with<br />
chronic HCV-1<br />
monoinfection and less<br />
than 1 log10 reduction<br />
HCV RNA after TW 4<br />
without cirrhosis,TW 12<br />
if HCV RNA less than<br />
100=addl 12wks if HCV<br />
RNA greater or equal to<br />
100=no addl,TW 24 if<br />
HCV RNA<br />
undetectable=addl<br />
24wks if HCV RNA<br />
detectable=no addl.<br />
Chronic HCV-1<br />
monoinfection and<br />
advanced<br />
fibrosis/compensated<br />
cirrhosis,TW 12 if HCV<br />
RNA less than 100=addl<br />
12 wks if HCV RNA<br />
greater or equal to<br />
100=no addl,TW 24 if<br />
HCV RNA<br />
undetectable=addl<br />
24wks if HCV RNA<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
236
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
VIMPAT SOLN. 2<br />
VIMPAT TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
detectable=no addl.<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Diabetic<br />
neuropathic<br />
pain. Seizure<br />
disorders. N/A N/A N/A N/A<br />
All FDAapproved<br />
N/A N/A N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months.<br />
<strong>Authorization</strong><br />
will be for 12<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
237<br />
OTHER<br />
CRITERIA<br />
Diabetic<br />
neuropathic pain<br />
(DPN), approve<br />
if the patient has<br />
tried at least two<br />
other therapies<br />
for DPN -<br />
tricyclic<br />
antidepressants<br />
(eg,<br />
nortriptyline),<br />
serotonin and<br />
norepinephrine<br />
reuptake<br />
inhibitors<br />
(SNRIs) (eg,<br />
Cymbalta,<br />
venlafaxine<br />
extended-release<br />
[Effexor XR]),<br />
gabapentin,<br />
Lyrica, or<br />
Lidoderm.<br />
Diabetic<br />
neuropathic pain
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
VINBLASTINE<br />
SULFATE INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Diabetic<br />
neuropathic<br />
pain. Seizure<br />
disorders.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
months.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
238<br />
OTHER<br />
CRITERIA<br />
(DPN), approve<br />
if the patient has<br />
tried at least two<br />
other therapies<br />
for DPN -<br />
tricyclic<br />
antidepressants<br />
(eg,<br />
nortriptyline),<br />
serotonin and<br />
norepinephrine<br />
reuptake<br />
inhibitors<br />
(SNRIs) (eg,<br />
Cymbalta,<br />
venlafaxine<br />
extended-release<br />
[Effexor XR]),<br />
gabapentin,<br />
Lyrica, or<br />
Lidoderm.
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
vincasar pfs inj. 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
239<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
vincristine inj. 1<br />
vinorelbine inj 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
240<br />
OTHER<br />
CRITERIA
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
voriconazole tab 1<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D worded<br />
as invasive<br />
aspergillosis,<br />
esophageal<br />
candidiasis,<br />
treatment of<br />
fungal<br />
infections<br />
caused by<br />
Scedosporium<br />
apiospermum<br />
and Fusarium<br />
spp., and<br />
treatment of N/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Esophageal candidasis<br />
requires a trial of one<br />
other systemic agent<br />
(eg., fluconazole, IV<br />
amphotericin B,<br />
itraconazole). N/A N/A<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
241<br />
OTHER<br />
CRITERIA<br />
For safety<br />
reasons, if there<br />
is insufficient<br />
information<br />
available to<br />
make a<br />
determination<br />
regarding<br />
coverage and<br />
the prescribing<br />
physician or<br />
representative of<br />
the physician<br />
cannot be<br />
contacted, then<br />
approve 14-day<br />
course.
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
candidemia in<br />
nonneutropeni<br />
c patients and<br />
the following<br />
Candida<br />
infections:<br />
disseminated<br />
infections in<br />
skin and<br />
infections in<br />
the abdomen,<br />
kidney,<br />
bladder wall,<br />
and wounds,<br />
treatment/prev<br />
ention of other<br />
serious<br />
systemic or<br />
suspected<br />
systemic<br />
fungal<br />
infections.<br />
Continuation<br />
therapy for<br />
patients<br />
started/stabiliz<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
242
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
VOTRIENT<br />
TAB 2<br />
XENAZINE<br />
TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
ed on<br />
intravenous<br />
(IV) or oral<br />
voriconazole<br />
for a systemic<br />
infection.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D.<br />
Tardive<br />
dyskinesia<br />
(TD). Tourette<br />
syndrome and<br />
related tic<br />
disorders.<br />
Primary N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Requires the<br />
prescriber to be an<br />
Oncologist or be in<br />
under the direct<br />
consultation with<br />
an Oncologist.<br />
For treatment of<br />
chorea associated<br />
with Huntington's<br />
disease, Tourette<br />
syndrome or<br />
related tic<br />
disorders, primary<br />
hyperkinetic<br />
dystonia, or<br />
hemiballism,<br />
Xenazine must be<br />
prescribed by or<br />
after consultation<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of plan<br />
year subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
243<br />
OTHER<br />
CRITERIA<br />
N/A<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
XEOMIN INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
hyperkinetic<br />
dystonia.<br />
Hemiballism.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. Plus<br />
Achalasia.<br />
Anal Fissure.<br />
BPH. Chronic<br />
facial<br />
pain/pain<br />
associated<br />
with TMJ<br />
dysfunction.<br />
Chronic low<br />
back pain.<br />
Headache<br />
(migraine,<br />
chronic<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Use in the<br />
management of<br />
cosmetic uses<br />
(eg, facial<br />
rhytides, frown<br />
lines, glabellar<br />
wrinkling,<br />
horizontal neck<br />
rhytides, mid<br />
and lower face<br />
and neck<br />
rejuvenation,<br />
platsymal bands,<br />
rejuvenation of<br />
the peri-orbital<br />
region), allergic<br />
rhinitis, gait<br />
freezing in<br />
Parkinsons N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
with a neurologist.<br />
For TD, Xenazine<br />
must be prescribed<br />
by or after<br />
consultation with a<br />
neurologist or<br />
psychiatrist.<br />
COVERAGE<br />
DURATION<br />
Tinnitus if<br />
prescribed by ENT.<br />
Headache if <strong>Authorization</strong><br />
prescribed by, or will be for 12<br />
after consultation months, unless<br />
with, a neurologist otherwise<br />
or HA specialist. specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
244<br />
OTHER<br />
CRITERIA<br />
Primary axillary<br />
hyperhydrosis<br />
after trial with at<br />
least 1 topical<br />
agent (eg,<br />
aluminum<br />
chloride). BPH<br />
after trial with at<br />
least 2 other<br />
therapies (eg,<br />
alpha1-blocker,<br />
5 alphareductase<br />
inhibitor,<br />
TURP,<br />
transurethral<br />
microwave heat<br />
treatment,<br />
TUNA,
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
tension HA,<br />
whiplash,<br />
chronic daily<br />
HA).<br />
Palmar/plantar<br />
and facial<br />
hyperhidrosis.<br />
Myofascial<br />
pain. Salivary<br />
hypersecretion<br />
. Spasticity<br />
(eg, due to<br />
cerebral palsy,<br />
stroke, brain<br />
injury, spinal<br />
cord injury,<br />
MS,<br />
hemifacial<br />
spasm).<br />
Essential<br />
tremor.<br />
Dystonia other<br />
than cervical<br />
(eg, focal<br />
dystonias,<br />
tardive<br />
EXCLUSION<br />
CRITERIA<br />
disease,<br />
vaginismus,<br />
interstitial<br />
cystitis, or<br />
Crocodile tears<br />
syndrome.<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
interstitial laser<br />
therapy, stents,<br />
various forms of<br />
surgery).<br />
Chronic low<br />
back pain after<br />
trial with at least<br />
2 other<br />
pharmacologic<br />
therapies (eg,<br />
NSAID,<br />
antispasmodics,<br />
muscle<br />
relaxants,<br />
opioids,<br />
antidepressants)<br />
and if being<br />
used as part of a<br />
multimodal<br />
therapeutic pain<br />
management<br />
program.<br />
Tinnitus after a<br />
trial with at least<br />
2 other<br />
pharmacologic<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
245
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
dystonia,<br />
anismus).<br />
Bladder/voidin<br />
g/urethral<br />
dysfunction.<br />
Frey's<br />
syndrome<br />
(gustatory<br />
sweating).<br />
Ophthalmic<br />
disorders (eg,<br />
esotropia,<br />
exotropia,<br />
nystagmus,<br />
facial nerve<br />
paresis).<br />
Speech/voice<br />
disorders (eg,<br />
dysphonias).<br />
Tourette's<br />
syndrome.<br />
Additional<br />
indications<br />
will be<br />
evaluated by a<br />
pharmacist<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
therapies (eg,<br />
lidocaine,<br />
antihistamines,<br />
antidepressants,<br />
anxiolytics,<br />
diuretics,<br />
anticonvulsants,<br />
antispastics) and<br />
tinnitus<br />
retraining<br />
therapy.<br />
Headache (eg,<br />
migraine,<br />
chronic tension<br />
headache,<br />
whiplash,<br />
chronic daily<br />
headache) after<br />
a trial with at<br />
least 2 other<br />
pharmacologic<br />
therapies (eg,<br />
anticonvulsants,<br />
antidepressants,<br />
beta-blockers,<br />
calcium channel<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
246
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
and/or a<br />
physician on a<br />
case-by-case<br />
basis.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
blockers, nonsteroidal<br />
antiinflammatory<br />
drugs).<br />
Palmar/plantar<br />
and facial<br />
hyperhidrosis<br />
after a trial with<br />
at least 1 topical<br />
agent (eg,<br />
aluminum<br />
chloride).<br />
Essential tremor<br />
after a trial with<br />
at least 1 other<br />
pharmacologic<br />
therapy (eg,<br />
primidone,<br />
propranolol,<br />
benzodiazepines<br />
, gabapentin,<br />
topiramate).<br />
Bladder/Voiding<br />
/Urethral<br />
dysfunction<br />
after a trial with<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
247
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
at least 1 other<br />
pharmacologic<br />
therapy (eg, oral<br />
antimuscarinic<br />
agents).<br />
Gastroparesis<br />
after a trial with<br />
at least 1<br />
promotility drug<br />
(eg,<br />
metoclopramide,<br />
tegasterod,<br />
erythromycin).<br />
Tourette's<br />
syndrome if<br />
after a trial with<br />
at least 1 more<br />
commonly used<br />
pharmacologic<br />
therapy (eg,<br />
neuroleptics,<br />
clonidine,<br />
SSRIs,<br />
psychostimulant<br />
s).<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
248
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
XOLAIR INJ. 2 All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
N/A<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
Moderate to severe Patients aged 12<br />
persistent asthma, years and older.<br />
baseline IgE level of at<br />
least 30 IU/mL. For<br />
asthma, patient has a<br />
positive skin test or in<br />
vitro testing (ie, a blood<br />
test for allergen-specific<br />
IgE antibodies such as<br />
the RAST) for 1 or more<br />
perennial aeroallergens<br />
(eg, house dust mite,<br />
animal dander [dog, cat],<br />
cockroach, feathers,<br />
mold spores) and/or for<br />
1 or more seasonal<br />
aeroallergens (grass,<br />
pollen, weeds).<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Moderate to severe <strong>Authorization</strong><br />
persistent asthma if will be for 12<br />
prescribed by, or in months, unless<br />
consultation with otherwise<br />
an allergist, specified.<br />
immunologist, or<br />
pulmonologist.<br />
SAR/PAR if<br />
prescribed by an<br />
allergist,<br />
immunologist, or<br />
pulmonologist.<br />
EG/EE/EC, if<br />
prescribed by or in<br />
consultation with<br />
an allergist,<br />
immunologist, or<br />
gastroenterologist.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
249<br />
OTHER<br />
CRITERIA<br />
Moderate to<br />
severe persistent<br />
asthma must<br />
meet all criteria.<br />
Patient's asthma<br />
symptoms have<br />
not been<br />
adequately<br />
controlled by<br />
concomitant use<br />
of at least 2<br />
months of<br />
inhaled<br />
corticosteroid<br />
and a longacting<br />
betaagonist<br />
(LABA)<br />
or LABA<br />
alternative, if<br />
LABA<br />
contraindicated<br />
or pt has<br />
intolerance then<br />
alternatives<br />
include<br />
sustained-
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
release<br />
theophylline or<br />
a leukotriene<br />
modifier (eg,<br />
montelukast),<br />
AND inadequate<br />
control<br />
demonstrated by<br />
hospitalization<br />
for asthma,<br />
requirement for<br />
systemic<br />
corticosteroids<br />
to control<br />
asthma<br />
exacerbation(s),<br />
or increasing<br />
need (eg, more<br />
than 4 times a<br />
day) for shortacting<br />
inhaled<br />
beta2 agonists<br />
for symptoms<br />
(excluding<br />
preventative use<br />
for exercise-<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
250
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
XOPENEX<br />
NEB 2<br />
XTANDI CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination. N/A N/A N/A N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
Prescribed by or in<br />
consult with<br />
Oncology<br />
Specialist<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
251<br />
OTHER<br />
CRITERIA<br />
induced<br />
asthma).<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ZALTRAP INJ. 2<br />
ZANOSAR INJ 2<br />
ZEMPLAR CAP 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
formulary<br />
change and<br />
member<br />
eligibility.<br />
determination. N/A N/A N/A N/A N/A N/A<br />
This drug may<br />
be covered N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
252<br />
OTHER<br />
CRITERIA<br />
N/A
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ZEMPLAR INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
253<br />
OTHER<br />
CRITERIA
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
zonisamide cap 1<br />
ZORTRESS<br />
TAB 2<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A N/A<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
N/A<br />
This drug may<br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the N/A N/A N/A N/A N/A N/A<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
254
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
ZYTIGA TAB 2<br />
ZYVOX SUSP. 2<br />
ZYVOX TAB 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
determination.<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D. N/A N/A N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
Approved for<br />
duration of<br />
contract year<br />
subject to<br />
Prescribed by or in formulary<br />
consult with<br />
Oncology<br />
Specialist<br />
change and<br />
member<br />
eligibility. N/A<br />
Infectious Disease<br />
Specialist or in<br />
consultation with<br />
an Infectious<br />
Disease Specialist<br />
concerning the<br />
patient. 3 months N/A<br />
Infectious Disease<br />
Specialist or in<br />
consultation with<br />
an Infectious<br />
Disease Specialist<br />
concerning the<br />
patient. 3 months N/A<br />
OTHER<br />
CRITERIA<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
255