2013 Prior Authorization Drug Requirements - CCHP

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