2013 Prior Authorization Drug Requirements - CCHP

FORMULARY
DRUG
BRAND NAME
generic name
albuterol neb 1
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
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
advanced, or metastatic
member
disease. For the
eligibility.
treatment of patients
with advanced renal cell
carcinoma after failure
of treatment with Sutent
or Nexavar. For the
treatment of patients
with subependymal giant
cell astrocytoma
associated with tuberous
sclerosis who require
therapeutic intervention
but are not candidates
for curative surgical
resection.
This drug may
be covered
under
Medicare Part
B or D
depending
upon the
circumstances.
Information
may need to 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
13
OTHER
CRITERIA