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 indications not otherwise excluded from Part D. Plus patient already started on dalfampridine extendedrelease for Multiple Sclerosis (MS). EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION consultation with, an MS specialist. COVERAGE DURATION OTHER CRITERIA Subsequent MS, authorize authorization for for 90 days. 12 mos if patient After up to 90 had a response. days of dalfampridine extended-release therapy, if MS patient has had a response to therapy as determined by prescribing physician (eg, increased walking distance, improved leg/limb strength, improvement in activities of daily living), then an additional authorization is allowed. 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 18
FORMULARY DRUG BRAND NAME generic name ANDROGEL 2 ARALAST NP INJ 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 excluded from Part D. N/A All FDAapproved indications not otherwise excluded from Part D. Alpha- 1 antitrypsin (AAT) deficiencyassociated panniculitis. N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION Two morning testosterone levels fall below the normal range for a healthy adult male. N/A 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 19 N/A For AAT deficiency with emphysema (or COPD), approve in patients with baseline (pretreatment) alpha1- antitrypsin serum concentration less than 11 microM (11 micromol/L) or 80 mg/dL. N/A N/A Approved for duration of contract year subject to formulary change and member eligibility. Authorization will be for 12 months, unless otherwise specified. OTHER CRITERIA N/A For all covered uses, the patient is required to try Aralast NP first line. For AAT deficiency with emphysema (or COPD), approve in patients with baseline (pretreatment) alpha1- antitrypsin serum concentration less than 11 microM (11 micromol/L) or
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2013 Prior Authorization Drug Requirements - CCHP

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