2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name REGRANEX GEL 2 DRUG TIER LEVEL COVERED USES make the determination. 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. Plus any granulating ulcer/wound (eg, pressure ulcers, venous stasis ulcers) that is classified as NPUAP Stage III or IV. Any clean and granulating ulcer/wound classified as NPUAP Stage II. N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION Diabetic neuropathic ulcer(s) that is/are classified as NPUAP Stage III or IV. Any clean and granulating ulcer/wound classified as Stage II (e.g., Stage II diabetic neuropathic ulcers and pressure ulcers), III or IV. N/A N/A PRESCRIBER RESTRICTION 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 186 OTHER CRITERIA Diabetic neuropathic ulcer(s) that is/are classified as NPUAP Stage III or IV. Any granulating ulcer/wound classified as Stage III or IV. Any clean and granulating ulcer/wound classified as Stage II (e.g., Stage II diabetic neuropathic ulcers and pressure ulcers), if the patient has tried other standard ulcer/wound care therapies
FORMULARY DRUG BRAND NAME generic name RELISTOR INJ. 2 REMICADE INJ. 2 DRUG TIER LEVEL COVERED USES All FDAapproved indications not otherwise excluded from Part D. All FDA approved indications not otherwise excluded from Part D. Crohn disease. Ankylosing spondylitis. Plaque psoriasis. Rheumatoid CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA N/A N/A REQUIRED MEDICAL INFORMATION Initial Therapy: Member must meet all 3 criteria. 1.Opioid-induced constipation. 2.Advanced illness receiving palliative care. 3.Failed 2 laxative/bowel therapies. N/A Rheumatoid Arthritis. Tried 1 diseasemodifying antirheumatic drug for 2 mos or concurrently receiving methotrexate (MTX). Crohn Disease (CD) for induction of remission (IR). Tried corticosteroid (CS) or CSs contraindicated or if currently on CS. CD for AGE RESTRICTION Rheumatoid arthritis (RA) and SD, Adults. 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 187 N/A N/A OTHER CRITERIA (eg, debridement, topical therapies [collagenase]) for at least 4 weeks. Initial=1 kit.Continuation of therapy approved for duration of contract year subject to member elegi N/A If contraindication s to nearly all other tx,exceptions to be evaluated by CD (w/ or w/out pharmacist fistulas)=12 wks and/or MD on for induction of case-by-case remission basis. Ulcerative (IR).All other colitis (UC). conds=12mos. Tried 2-mo trial
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2013 Prior Authorization Drug Requirements - CCHP

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