2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name KEPIVANCE INJ 2 KINERET INJ. 2 DRUG TIER LEVEL COVERED USES Part D. All medically accepted indications not otherwise excluded from Part D This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION change and member eligibility. determination. N/A N/A N/A N/A N/A N/A All FDAapproved Rheumatoid Approved for arthritis (RA) and duration of indications not N/A N/A Still's disease, N/A contract year CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program. H0571_2013_142_FINAL_2 Approved 11282012 110 OTHER CRITERIA Adults with RA. Tried adalimumab,
CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 FORMULARY DRUG BRAND NAME generic name DRUG TIER LEVEL COVERED USES otherwise excluded from Part D. EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION adults. PRESCRIBER RESTRICTION COVERAGE DURATION subject to formulary change and member eligibility. OTHER CRITERIA certolizumab pegol, golimumab, etanercept, or infliximab for at least 2 months or was intolerant to one of these therapies. JIA/JRA (regardless of onset), approve if patient has tried etanercept, adalimumab, infliximab, or abatacept for at least 2 months or was intolerant to one of these therapies. Systemic onset of JIA, approve if patient has tried a systemic corticosteroid CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program. H0571_2013_142_FINAL_2 Approved 11282012 111
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2013 Prior Authorization Drug Requirements - CCHP

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