2013 Prior Authorization Drug Requirements - CCHP

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CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 FORMULARY DRUG BRAND NAME generic name DRUG TIER LEVEL COVERED USES neutropenia, cyclic neutropenia, idiopathic neutropenia). Neutropenia associated with human immunodefici ency virus (HIV) or acquired immunodefici ency syndrome (AIDS). Treatment of myelodysplast ic syndromes (MDS). Drug induced agranulocytosi s or neutropenia. Aplastic anemia (AA). EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA 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 140
FORMULARY DRUG BRAND NAME generic name NEXAVAR TAB 2 NUEDEXTA CAP 2 ondansetron inj 1 DRUG TIER LEVEL COVERED USES Acute lymphocytic leukemia (ALL). CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA All FDAapproved indications not otherwise excluded from Part D. N/A N/A All FDAapproved indications not otherwise excluded from REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION Prescribed by a Oncologist or Require patient to under the direct be at least 18 years consultation of an old. Oncologist. COVERAGE DURATION Approved for duration of contract year subject to formulary change and member eligibility. Authorization will be for 12 months. Part D. N/A N/A N/A N/A N/A This drug may be covered under Medicare Part B or D depending upon the circumstances. 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 141 OTHER CRITERIA N/A
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2013 Prior Authorization Drug Requirements - CCHP

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