2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name orphenadrine compound ds tab 1 orphenadrine citrate er tab 1 DRUG TIER LEVEL COVERED USES 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 Part D. N/A N/A REQUIRED MEDICAL INFORMATION AGE RESTRICTION Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. N/A Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. N/A PRESCRIBER RESTRICTION COVERAGE DURATION Authorization will be for 1 month. Authorization will be for 1 month. 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 146 OTHER CRITERIA if the patient has tried one of the following biologic DMARDs, adalimumab, etanercept, or infliximab for at least 2 months or was intolerant to one of these therapies. Musculoskeletal conditions/disor ders, approve if the patient has tried two other therapies for the current condition. Musculoskeletal conditions/disor ders, approve if the patient has tried two other therapies for the
FORMULARY DRUG BRAND NAME generic name orphenadrine/asp irin/caffeine 1 oxaliplatin inj 1 DRUG TIER LEVEL COVERED USES 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 REQUIRED MEDICAL INFORMATION AGE RESTRICTION Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. N/A PRESCRIBER RESTRICTION COVERAGE DURATION Authorization will be for 1 month. 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 make the determination. 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 147 OTHER CRITERIA current condition. Musculoskeletal conditions/disor ders, approve if the patient has tried two other therapies for the current condition.
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2013 Prior Authorization Drug Requirements - CCHP

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