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 Arthritis. Still’s disease. Psoriatic arthritis. Ulcerative colitis. Behcet syndrome uveitis. Celiac sprue. Erythrodermic psoriasis. Giant cell arteritis. Graft versus host disease. Hidradenitis suppurativa. Juvenile idiopathic arthritis. Pustular psoriasis. Pyoderma gangrenosum. Sarcoidosis. Uveitis. EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION maintenance of remission (MR). Got 3 infliximab (IFB) doses and responded, or tried azathioprine (AZA), 6- mercaptopurine (6MP), MTX, adalimumab, or certolizumab pegol. Fistulizing CD (FCD) for IR, approve. FCD for MR. Got 3 doses of IFB and responded. Plaque psoriasis (PP). A minimum body surface area (BSA) of 5% or more, exceptions for less than 5% BSA if PP of palms, soles, head/neck, nails, intertriginous areas or genitalia or inadequate response to 2-mo trial of topical therapy (tx) OR localized phototx (ultraviolet B [UVB] or oral methoxsalen plus AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA of systemic CS, 6-MP, AZA, CSA or tacrolimus. Uveitis.Tried periocular/intrao cular CS, systemic CS, immunosuppres sant (eg, MTX, mycophenolate mofetil, CSA, AZA, cyclophosphami de), etanercept, adalimumab. Pyoderma gangrenosum (PG).Tried 1 systemic tx (eg, systemic CS, immunosuppres sant (eg, AZA, 6MP, CSA, cyclophosphami de, 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 188
FORMULARY DRUG BRAND NAME generic name REMODULIN INJ. 2 DRUG TIER LEVEL COVERED USES Wegener granulomatosi s. CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION UVA light [PUVA]), and inadequate response to 2-mo trial of systemic tx (w/ one of-MTX, cyclosporine (CSA), acritretin, adalimumab, alefacept, etanercept, or ustekinumab) or contraindications to all, and significant disability or impairment in physical or mental functioning according to treating physician (MD).Tried systemic tx (MTX, CSA, acritretin, etanercept, alefacept, adalimumab, or ustekinumab) for 2 mos or phototx (UVB or PUVA) for 2 mos. AGE RESTRICTION All FDA approved indications not otherwise excluded from N/A N/A N/A N/A PRESCRIBER RESTRICTION COVERAGE DURATION Initial=36 weeks. Continuation of therapy approved for 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 189 OTHER CRITERIA chlorambucil), etanercept or adalimumab) for 2 mos, or 2-mo trial of intralesional CS or CSA for localized PG. Graft versus host disease (GVHD).Tried 1 tx (eg, high-dose CS, antithymocyte globulin, CSA, thalidomide, tacrolimus, mycophenolate mofetil, etc.) or receiving IFB concurrently. N/A
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2013 Prior Authorization Drug Requirements - CCHP

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