2013 Prior Authorization Drug Requirements - CCHP

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
or pegylated
interferon alfa
2a/2b
products).
Anemia in
HIV-infected
patients.
Anemia in
heart failure
(HF).
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
g/dL or less.Anemia due
to ribavirin for Hep C,
Hb is 10.0 g/dL or less at
tx start. All conds, deny
if Hb exceeds 12.0 g/dL.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
30%).
Continuation
and reinstitution
of epoetin alfa
must include a
dose reduction
of 25% from the
previously
administered
dose.
Continuation
and reinstitution
of Aranesp must
include a dose
reduction of
25% from the
previously
administered
dose. Anemia in
HF, approve
initial trial of up
to 2 months for
patients with
more severe HF,
Hb of 10.0 g/dL
or less, anemia
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
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