2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name REVATIO TAB 2 RITUXAN INJ. 2 DRUG TIER LEVEL COVERED USES Part D. Pulmonary arterial hypertension (WHO Class I) with NYHA Class II, III or IV symptoms. 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 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION For initial approval for use in pulmonary arterial hypertension (PAH), approve if patient has had a right-heart catheterization to confirm diagnosis of PAH to ensure appropriate medical assessment. For patients currently receiving sildenafil or tadalafil, approve if patient has a diagnosis of PAH. N/A AGE RESTRICTION All FDAapproved indications not otherwise N/A N/A RA, adults. PRESCRIBER RESTRICTION COVERAGE DURATION duration of contract year. 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 190 OTHER CRITERIA For PAH, if Authorization prescribed by, or in will be for 12 consultation with, a months, unless cardiologist or a pulmonologist. otherwise specified. N/A Adult with RA RA.Approve 2 Adult with RA (initial and repeat doses.16 wks or (initial course), courses). more after, approve if Prescribed by a approve 2 more patient has tried
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. All medicallyaccepted indications not otherwise excluded from Part D. Patients already started on Rituxan for rheumatoid arthritis (RA). EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION rheumatologist or in consultation with a rheumatologist. Non-RA indications, if prescribed by or in consultation with an oncologist, hematologist, neurologist, multiple sclerosis (MS) specialist, rheumatologist, dermatologist, or immunologist, or who are being managed by a transplant center. COVERAGE DURATION doses if response per doctor.Othr=12 mos. OTHER CRITERIA at least 1 of the following biologic DMARDs, etanercept, certolizumab pegol, golimumab, infliximab, or adalimumab, for at least 2 months. Adult with RA (repeat course), approve if 16 weeks or more after the first dose of the previous rituximab regimen and the patient has responded (eg, less joint pain, morning stiffness, or fatigue, or 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 191
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2013 Prior Authorization Drug Requirements - CCHP

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