2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name PROMACTA TAB 2 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 All FDAapproved indications not otherwise excluded from Part D. Thrombocytop enia due to hepatitis C virus (HCV)- related cirrhosis. N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION Cause of thrombocytopenia. 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 172 N/A Treatment of thrombocytopenia due to chronic immune (idiopathic) thrombocytopenic purpura (ITP), approve if prescribed by, or after consultation with, a hematologist. Treatment of thrombocytopenia due to HCVrelated cirrhosis, approve if prescribed by, or Authorization will be for 12 months. OTHER CRITERIA alpha1- antitrypsin serum concentration less than 11 microM (11 micromol/L) or 80 mg/dL. For treatment of thrombocytopen ia due to HCVrelated cirrhosis, approve to allow for initiation of antiviral therapy.
FORMULARY DRUG BRAND NAME generic name promethazine syrup 1 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA All FDAapproved indications not otherwise excluded from Part D. N/A N/A REQUIRED MEDICAL INFORMATION AGE RESTRICTION Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. N/A PRESCRIBER RESTRICTION after consultation with, either a gastroenterologist or a physician who specializes in infectious disease. COVERAGE DURATION Authorization will be for 12 months, unless otherwise specified. 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 173 OTHER CRITERIA Approve if the patient has tried a prescription oral second generation antihistamine product (cetirizine, fexofenadine, desloratadine, levocetirizine, fexofenadine/ps eudoephedrine, or desloratadine/ps eudoephedrine) for the current condition. Approve promethazine
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2013 Prior Authorization Drug Requirements - CCHP

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