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
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
or because the
patient has a
chronic and
complex
existing
medication
regimen in
which an oral
bisphosphonate
agent will likely
compromise
therapy as
determined by
the prescribing
physician, this
exception will
be evaluated by
a pharmacist
and/or physician
on a case-bycase
basis, or
because the
patient has a
pre-existing
gastrointestinal
medical
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
184