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 replacement surgery. Prevention of venous thromboembol ism after knee replacement surgery. Additional indications will be evaluated by a pharmacist and/or a physician on a case-by-case basis. EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA additional indications evaluated by a pharmacist and/or a physician on a case-by-case basis, if the patient has tried one of the following therapies for the condition: warfarin (Coumadin), fondaparinux (Arixtra), or a low molecular weight heparin (LMWH) product (enoxaparin [Lovenox], tinzaparin [Innohep], dalteparin 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 160
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 [Fragmin]), OR if the patient is unable to take one of these medications listed for the condition for one of the following reasons: patient has allergic, immunologic or inherited disorder, patient had adverse effect (eg, major organ toxicity, major bleeding), the patient has experienced ineffectiveness to the agent in a prior setting, the patient has drugdrug interactions that cannot be 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 161
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2013 Prior Authorization Drug Requirements - CCHP

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