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 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA wks (total), or HC genotypes 1/4 authorize 12 wks initial tx (document baseline HCV RNA) and reassess viral titer at 12 wks, if decreased by 2log10 or more and virus is undetectable, authorize 36 wks (total 48 wks), or if not decreased by 2log 10, authorize 12 wks and reassess at 24 wks, or genotype 1 w/ viral titer decrease of 2log10 but virus 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 150
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 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA still detectable, authorize 12 wks and reassess at 24 wks. At 24 wk, if advanced fibrosis (via liver bx) and undetectable virus, authorize 24 wks (48 wks total), or if advanced fibrosis and detectable HCV RNA MD and pt to decide whether to cont w/ another 24 wks OR If no advanced fibrosis and do not have greater than or equal to 2 log10 decrease or virus 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 151
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2013 Prior Authorization Drug Requirements - CCHP

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