2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name INJ. NEPHRAMINE INJ. 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 PRESCRIBER RESTRICTION COVERAGE DURATION 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 determination. 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 136 OTHER CRITERIA
FORMULARY DRUG BRAND NAME generic name DRUG TIER LEVEL COVERED USES describing the use and setting of the drug to make the determination. 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 Cancer patients receiving chemotherapy, if prescribed by or in consultation with an oncologist or hematologist. Radiation injury, if prescribed by, or in COVERAGE DURATION All FDAapproved indications not otherwise excluded from Part D but worded more broadly as Radiation injury, approve if the estimated whole body or significant partial-body exposure is at least 3 Grays in adults aged less than 60 years, or at least 2 Grays in children consultation with, a NEULASTA cancer patients receiving myelosuppress ive (aged 12 years or less) or in adults aged 60 years or older, or in those who have major trauma physician with experience in treating acute radiation Authorization will be for 12 months, unless otherwise INJ. 2 chemotherapy. N/A injuries or burns. N/A syndrome. specified. NEUMEGA INJ. 2 This drug may 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 137 OTHER CRITERIA Radiation injury, approve if the estimated whole body or significant partial-body exposure is at least 3 Grays in adults aged less than 60 years, or at least 2 Grays in children (aged 12 years or less) or in adults aged 60 years or older, or in those who have major trauma injuries or burns.
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2013 Prior Authorization Drug Requirements - CCHP

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