2013 Prior Authorization Drug Requirements - CCHP
2013 Prior Authorization Drug Requirements - CCHP
2013 Prior Authorization Drug Requirements - CCHP
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FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
NEUPOGEN<br />
INJ. 2<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
be covered<br />
under<br />
Medicare Part<br />
B or D<br />
depending<br />
upon the<br />
circumstances.<br />
Information<br />
may need to<br />
be submitted<br />
describing the<br />
use and setting<br />
of the drug to<br />
make the<br />
determination.<br />
All FDAapproved<br />
indications not<br />
otherwise<br />
excluded from<br />
Part D worded<br />
more broadly<br />
as cancer<br />
patients<br />
receiving<br />
myelosuppressN/A<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
Radiation injury,<br />
approve if the estimated<br />
whole body or<br />
significant partial-body<br />
exposure is at least 3<br />
Grays in adults aged less<br />
than 60 years, or at least<br />
2 Grays in children<br />
(aged 12 years or less) or<br />
in adults aged 60 years<br />
or older, or in those who N/A<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
Cancer/AML,<br />
PBPC, MDS, AA,<br />
ALL, oncologist or<br />
a hematologist.<br />
SCN, hematologist.<br />
HIV/AIDS<br />
neutropenia,<br />
infectious disease<br />
(ID) physician<br />
(MD),<br />
hematologist, or<br />
COVERAGE<br />
DURATION<br />
<strong>Authorization</strong><br />
will be for 12<br />
months, unless<br />
otherwise<br />
specified.<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
138<br />
OTHER<br />
CRITERIA<br />
Radiation<br />
injury, approve<br />
if the estimated<br />
whole body or<br />
significant<br />
partial-body<br />
exposure is at<br />
least 3 Grays in<br />
adults aged less<br />
than 60 years, or<br />
at least 2 Grays
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