2013 Prior Authorization Drug Requirements - CCHP

FORMULARY
DRUG
BRAND NAME
generic name
melphalan inj. 2
DRUG
TIER
LEVEL
COVERED
USES
Endometriosis
(Lupon
Depot),
Uterine
leiomyomata
(Lupon
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
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to
be submitted N/A N/A N/A N/A N/A N/A
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
127
OTHER
CRITERIA
migraine
approve if the
patient has tried
two other
therapies for the
treatment of
acute migraine
(e.g., NSAIDs,
triptans,
ergotamines) or
prophylaxis of
migraine (e.g.,
beta-blockers,
amitriptyline,
divalproex).