2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name LUPRON DEPOT INJ. 3.75MG 2 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION be submitted describing the use and setting of the drug to make the determination. All FDAapproved indications not otherwise excluded from Part D but specific to the following drugs as follows: Prostate cancer (Lupron Depot OR Eligard), Endometriosis (Lupon Depot), Uterine leiomyomata (Lupon N/A N/A N/A N/A PRESCRIBER RESTRICTION COVERAGE DURATION CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program. H0571_2013_142_FINAL_2 Approved 11282012 124 OTHER CRITERIA Premenstrual syndrome (PMS) for patients that have tried two other therapies (e.g., selective serotonin reuptake inhibitors [SSRIs], oral contraceptives For [OCs]). dysfunctional Menstrual uterine bleeding migraine approve for up approve if the to 6 months and patient has tried all other two other indications x 12 therapies for the mos. treatment of
FORMULARY DRUG BRAND NAME generic name LUPRON DEPOT INJ. 7.5MG, 22.5MG, 30MG, 45MG 2 DRUG TIER LEVEL COVERED USES Depot), Treatment of central precocious puberty (Lupron Depot Ped). CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION All FDAapproved indications not otherwise excluded from Part D but specific to the following drugs as follows: Prostate cancer (Lupron Depot OR Eligard), Endometriosis (Lupon Depot), N/A N/A N/A N/A PRESCRIBER RESTRICTION COVERAGE DURATION CCHP Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program. H0571_2013_142_FINAL_2 Approved 11282012 125 OTHER CRITERIA acute migraine (e.g., NSAIDs, triptans, ergotamines) or prophylaxis of migraine (e.g., beta-blockers, amitriptyline, divalproex). Premenstrual syndrome (PMS) for patients that have tried two other therapies (e.g., selective serotonin reuptake For inhibitors dysfunctional [SSRIs], oral uterine bleeding contraceptives approve for up [OCs]). to 6 months and Menstrual all other migraine indications x 12 approve if the mos. patient has tried
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2013 Prior Authorization Drug Requirements - CCHP

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