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. Acute hep C (ie, infection within 6 mos of exposure), authorize 6 to 12 mos of tx if at least 2 to 4 mos after acute onset.Retreatme nt of pts who have been previously txd for HC w/ IA or PA, authorize 48 wks. Retreatment of pts who failed to attain a sustained virologic response (SVR) [undetectable HCV RNA at the end of txment and 24 wks after txment 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 154
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 completion] w/ PA and ribavirin is not recommended unless specific factors that contributed to the nonresponse are identified and corrected before retxment. Recurrent hep C after liver transplant and grade II fibrosis, authorize 48 wks if PA prescribed by hepatologist or liver transplant MD affiliated w/ liver transplant program.HC on waiting list for liver transplantation, 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 155
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2013 Prior Authorization Drug Requirements - CCHP

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