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 authorize initial 12 wks if administered in liver clinic affiliated with liver transplant program. At 12 wks, genotype 2/3 and viral titer decreased by 2log10 or more and virus undetectable authorize 24 wks total from the time pt has achieved an optimal dose of PA and ribavirin, for genotype 1 and viral titer decreased by 2log10 or more and virus undetectable 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 156
FORMULARY DRUG BRAND NAME generic name pentostatin 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 REQUIRED MEDICAL INFORMATION AGE RESTRICTION 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 157 OTHER CRITERIA authorize 52 wks total from the time pt has achieved an optimal dose of PA and ribavirin, or genotype 1/2/3 and viral titer not decreased by 2log10, then no further authorization. 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 N/A N/A N/A N/A N/A N/A
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2013 Prior Authorization Drug Requirements - CCHP

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