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 eudoephedrine, or desloratadine/ps eudoephedrine) for the current condition. Approve promethazine hydrochloride tablets or syrup if the patient has tried a prescription oral anti-emetic agent (ondansetron, granisetron, dolasetron, palonosetron, aprepitant) for the current condition. Approve diphenhydramin e (capsules or elixir) if the 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 176
FORMULARY DRUG BRAND NAME generic name PROVIGIL 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 N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION For the FDA-approved indication of excessive sleepiness due to obstructive sleep AGE RESTRICTION ADHD or ADD in patients less than 18 years. Adjunctive PRESCRIBER RESTRICTION Idiopathic hypersomnia must have the diagnosis confirmed by a COVERAGE DURATION Authorization will be for 12 months, unless otherwise 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 177 OTHER CRITERIA patient has tried at least two other FDAapproved products for the management of insomnia. Approve hydroxyzine hydrochloride (tablets and syrup) or hydroxyzine pamoate (capsules) if the patient has tried at least two other FDAapproved products for the management of anxiety. Excessive sleepiness due to OSAHS if the patient has tried
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2013 Prior Authorization Drug Requirements - CCHP

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