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 excluded from Part D. EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION apnea/hypoapnea syndrome (OSAHS) patients must have tried continuous positive airway pressure (CPAP). For the FDA-approved indication of excessive sleepiness due to shiftwork sleep disorder (SWSD), patients must be working at least 5 overnight shifts per month. AGE RESTRICTION augmentation treatment for depression must be in adults. PRESCRIBER RESTRICTION COVERAGE DURATION sleep specialist specified. physician or at an institution that specializes in sleep disorders. OTHER CRITERIA CPAP. Excessive sleepiness due to SWSD if the patient is working at least 5 overnight shifts per month. ADHD/ADD who have tried two alternative medications for ADHD/ADD from two different classes as follows: methylphenidate products (e.g. methylphenidate , dexmethylpheni date), amphetamines (e.g., mixed amphetamine salts, 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 178
FORMULARY DRUG BRAND NAME generic name PULMICORT 2 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION 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 179 OTHER CRITERIA dextroamphetam ine), atomoxetine, bupropion or tricyclic antidepressants (TCAs e.g., imipramine, desipramine). Adjunctive/aug mentation treatment for depression in adults if the patient is concurrently receiving other medication therapy for depression. This drug may be covered under Medicare Part B or D depending N/A N/A N/A N/A N/A N/A
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2013 Prior Authorization Drug Requirements - CCHP

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