2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name TESTIM GEL 2 TETANUS/ DIPHTHERIA TOXOID INJ. 2 DRUG TIER LEVEL COVERED USES Other superficial fungal skin infections. All FDAapproved indications not otherwise excluded from CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION solution with terbinafine is not permitted. AGE RESTRICTION Two morning testosterone levels fall below the normal range for a healthy adult male. Patient must have tried and failed ANDRODERM and ANDROGEL N/A N/A PRESCRIBER RESTRICTION COVERAGE DURATION Approved for duration of contract year subject to formulary change and member eligibility. Part D. N/A N/A This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the 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 202 OTHER CRITERIA fungal skin infections after a trial of a topical antifungal agent or an oral antifungal agent.
FORMULARY DRUG BRAND NAME generic name TEV-TROPIN INJ 2 DRUG TIER LEVEL COVERED USES use and setting of the drug to make the determination. All FDAapproved 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 Use in the management of acute critical illness due to complications of surgery, trauma, or with acute respiratory failure, as antiaging therapy, to improve REQUIRED MEDICAL INFORMATION Child/adolesc documented GH stim test (levodopa, insulininduced hypoglycemia, arginine, clonidine, glucagon) w/GH response less than 10 ng/mL AND baseline height (Ht) less than the 3rd percentile (pct) for gender/age AND pretx Ht growth rate (GR) functional status child less than 3 yrs of in elderly, less than 7 cm/yr and somatopause, child greater than or enhancement of equal to 3 yrs of less athletic ability, than 4 cm/yr OR child bone marrow any age GR less than the transplant 10th pct for age/gender (BMT) without based on min 6 mos of total body data.Child w/brain irradiation, bony radiation does not have AGE RESTRICTION TS, children. SHOX/CRI/NS, children/adolescent s. SGA, 2 to 8 yrs. HIV failure to thrive, less than 17 yrs. SBS/HIV cachexia/wasting, adults. PRESCRIBER RESTRICTION For adults, the endocrinologist must certify that the somatropin is not being prescribed for antiaging therapy or to enhance athletic ability. Child/adolesc must be evalaluated by pediatric endocrinologist COVERAGE DURATION GH DF 12 mos.SBS 4 wks/yr.Non-GH DF ISS 6 mos.HIV wast/cach 24 wks.HIV failure to thrive 12 wks. 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 203 OTHER CRITERIA Adult GH DF (start), document diagnosis of GH DF due to adultonset (GH alone or multiple hormone deficiencies/hyp opituitarism from pituitary dz, hypothalamic dz, surgery, cranial radiation tx, tumor txment, traumatic brain injury, or subarachnoid hemorrhage) or due to
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CCHP Senior Select Program (HMO SNP
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2013 Prior Authorization Drug Requirements - CCHP

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