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 undetectable, no further authorization, or if genotype 1 w/ 2log10 decrease AND detectable virus at wk 12 but no detectable virus at wk 24, then authorize for 48 wksHC viral genotype 5/6 use genotype 1/4 criteria above.Coinfecte d with HIV/HC (genotype 1,2,3,4) and not previously txd for HC, authorize up to 48 wks (total).Child 2 to 17 yrs w/HC (genotypes 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 152
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 1,2,3,4) not been previously txd for HC w/IA/PA AND not HIV co-infected, authorize 24 wks initial tx. At 24 wk, if viral titer undetectable after 24 wks or if viral titer decreased by 2log10 or more after 12 wks of tx, authorize 24 wks (48 wks total), or if viral titer still detectable after 24 wks of tx, then no further authorization.Co infected w/ HC and Hep B, authorize 48 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 153
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2013 Prior Authorization Drug Requirements - CCHP

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