2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name sildenafil tab 1 SIMPONI 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 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 For moderate to severe RA intolerance to or N/A N/A 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 192 OTHER CRITERIA improved mobility, or decreased soft tissue swelling in joints or tendon sheaths) as determined by the prescribing physician. 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 Approved For members through duration with a diagnosis
FORMULARY DRUG BRAND NAME generic name SIMULECT INJ 2 DRUG TIER LEVEL COVERED USES indications not otherwise excluded from Part D. CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION failure of therapy with methotrexate (greater than 20mg/wk) and 1 DMARD and Enbrel. Peripheral Ankylosing Spondylitis or Psoriatic Arthritis requires failure of 1 DMARD and Enbrel. AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION of contract year subject to formulary change and member eligibility. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting N/A N/A N/A N/A N/A N/A 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 193 OTHER CRITERIA of early, severeonset RA, additional required medical information is not required. Members with Axial Ankylosing Spondylitis, no other medical information is required.
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2013 Prior Authorization Drug Requirements - CCHP

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