2013 Prior Authorization Drug Requirements - CCHP

More documents

Recommendations

Info

FORMULARY DRUG BRAND NAME generic name ONFI TAB 2 ONTAK INJ. 2 DRUG TIER LEVEL COVERED USES 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 All FDA approved indications not otherwise excluded from Part D. N/A N/A REQUIRED MEDICAL INFORMATION AGE RESTRICTION Prior Authorization required for members 65 and older N/A PRESCRIBER RESTRICTION COVERAGE DURATION Approved for duration of contract year subject to formulary change and member eligibility. N/A This drug may 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 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 144 OTHER CRITERIA
FORMULARY DRUG BRAND NAME generic name ORENCIA INJ. 2 DRUG TIER LEVEL COVERED USES make the determination. 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. Plus patients who have already been started on abatacept for a covered use. N/A N/A REQUIRED MEDICAL INFORMATION AGE RESTRICTION Rheumatoid arthritis (RA), adults. PRESCRIBER RESTRICTION COVERAGE DURATION 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 145 N/A Authorization will be for 12 months, unless otherwise specified. OTHER CRITERIA RA, approve if the patient has tried one of the following biologic DMARDs, adalimumab, etanercept, certolizumab pegol, golimumab, or infliximab for at least 2 months, or was intolerant to one of these therapies. Juvenile idiopathic arthritis (JIA) [or Juvenile Rheumatoid Arthritis (JRA)], polyarticular course, approve
Page 1 and 2:
FORMULARY DRUG BRAND NAME generic n
Page 3 and 4:
Page 5 and 6:
CCHP Senior Select Program (HMO SNP
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94: CCHP Senior Select Program (HMO SNP
Page 101 and 102: FORMULARY DRUG BRAND NAME generic n
Page 143: FORMULARY DRUG BRAND NAME generic n
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209 and 210:
Page 211 and 212:
Page 213 and 214:
Page 215 and 216:
Page 217 and 218:
Page 219 and 220:
Page 221 and 222:
Page 223 and 224:
Page 225 and 226:
Page 227 and 228:
Page 229 and 230:
Page 231 and 232:
Page 233 and 234:
Page 235 and 236:
Page 237 and 238:
Page 239 and 240:
Page 241 and 242:
Page 243 and 244:
Page 245 and 246:
Page 247 and 248:
Page 249 and 250:
Page 251 and 252:
Page 253 and 254:
Page 255:
show all

2013 Prior Authorization Drug Requirements - CCHP

Create successful ePaper yourself

Delete template?

Save as template?