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 persists despite transfusions or pt has contraindication s to transfusions. Deny if Hb is more than 12.0 g/dL. Further approval after initial course will be determined on a case-by-case basis after evaluation by a pharmacist and/or physician. Anemia of chronic disease, approve initial trial of 3 months for patients with symptomatic anemia of 10.0 g/dL or less, 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 168
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 anemia persists despite transfusions or cannot tolerate or undergo transfusions, and/or low erythropoietin levels ot failure of other treatment modalities (eg, iron supplementation ). Other causes of anemia have been ruled out. Deny if Hb is more than 12.0 g/dL. Further approval after initial course will be determined on a case-by-case basis after 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 169
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