2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name SPRYCEL TAB 2 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 other superficial, systemic or suspected fungal infections. Patient has been started and stabilized on intravenous (IV) itraconazole therapy or oral itraconazole for a systemic infection and it is being used as continuation therapy. Candida onychomycosi s. All medicallyaccepted indications not N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION onychomycosis if they have a culture positive for Candida. Diagnosis for which Sprycel is being used. For indications of CML 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 196 N/A Authorization will be for 12 months. OTHER CRITERIA For CML, new patient must have Ph-positive
FORMULARY DRUG BRAND NAME generic name STREPTOMYCI N INJ. 1 DRUG TIER LEVEL COVERED USES 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 and ALL, the Philadelphia chromosome (Ph) status of the leukemia must be reported. New patients with CML and ALL which is Ph-positive may receive authorization for Sprycel. AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION 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 of the drug to make the determination. 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 197 OTHER CRITERIA CML for approval of Sprycel. For ALL, new patient must have Ph-positive ALL for approval of Sprycel.
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CCHP Senior Select Program (HMO SNP
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2013 Prior Authorization Drug Requirements - CCHP

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