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
itraconazole cap 1
DRUG
TIER
LEVEL
COVERED
USES
All FDAapproved
indications not
otherwise
excluded from
Part D. Tinea
corporis.
Tinea cruris,
faciei,
manuum,
imbricata, and
pedis
(nonmoccasin
or chronic
type). Plantaror
moccasintype
dry tinea
pedis. Tinea or
pityriasis
versicolor.
Tinea capitis.
Tinea barbae.
Treatment of
vaginal
candidiasis.
Prevention of N/A
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
Onychomycosis must be
judged to be medically
significant (causing
impaired mobility,
discomfort, or in the
presence of diabetes
mellitus, an
immunocompromised
condition) by the
treating physician and a
positive KOH, fungal
culture, DTM culture,
nail biopsy, or histologic
examination (PAS) is
required before therapy
initiation. Before a
second course of
treatment is permitted
for onychomycosis, a
culture must demonstrate
a fungal infection. Use
of topical ciclopirox 8%
solution with
itraconazole is not
permitted. Itraconazole
should not be given for N/A
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
N/A
COVERAGE
DURATION
Ony=12wks
toenails,8wks
fingernails.Cand
ida ony,4
mos.Other
conds=12mos.
OTHER
CRITERIA
Tinea corporis
after a trial of a
topical
antifungal agent,
except for
extensive
conditions.
Tinea cruris,
faciei, manuum,
imbricata, and
pedis
(nonmoccasin or
chronic type)
after a trial of a
topical
antifungal agent.
Tinea or
pityriasis
versicolor after
trial of a topical
antifungal agent,
except for
extensive
conditions.
Treatment of
vaginal
CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.
H0571_2013_142_FINAL_2 Approved 11282012
106