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 EXCLUSION CRITERIA dysplasias, burn injury, cardiac transplantation, central precocius puberty, chronic fatigue syndrome, congenital adrenal hyperplasia, constitutional delay of growth and puberty, corticosteroidinduced short stature including a variety of chronic glucocorticoiddependent conditions, such as asthma, juvenile rheumatoid arthritis, after REQUIRED MEDICAL INFORMATION to meet baseline Ht crit.Congenital hypopituitarism does not have to meet Ht or GR crit.Child w/hypophysectomy, approve.Child/adolesc GH DF cont tx, GR increased by 2.5 cm/yr or more in most recent yr (MRY) per MD AND epiphyses open (older than 12 yrs), both crit exclude adolesc w/hypopituitarism.Revie w GR annually (not applied to hypopituitarism).Adoles/ yng adult w/completed linear growth (GR less than 2 cm/yr), review for adult GH DF.Greater than 18 yrs, auth not allowed if midparental ht attained.ISS child w/open epiphyses,6 mo AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA childhood-onset (GH not rec in adults who had GH tx as child for uses not due to GH DF) AND negative response to 1 GH stim test (insulin tolerance [peak less than 5 mcg/L], or glucagon [peak less than 3 mcg/L]) [GHRH plus arginine may be used if available] (exclude stim test for childhood-onset due to mutations, lesions, congenital 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 204
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 EXCLUSION CRITERIA renal, heart, liver, or BMT, Crohn's disease, cystic fibrosis, dilated cardiomyopathy /heart failure, end-stage renal disease in adults undergoing hemodialysis, Down's syndrome, familial dysautonomia, fibromyalgia, HIV-infected patients with alterations in body fat distribution, infertility, kidney transplant patients (children) with a REQUIRED MEDICAL INFORMATION trial if baseline Ht less than 3rd pct (greater than 2 SD below mean for gender/age) AND pretx GR child less than 3 yrs of less than 7 cm/yr and child greater than or equal to 3 yrs of less than 4 cm/yr OR child any age GR less than the 10th pct for age/gender based on min 6 mos of data AND PE certifies child's basic activities of daily living limited by SS and has condition which GH is/may be effective AND PE certifies via bone-age x- ray, predicted adult Ht less than 3rd pct.Auth after initial tx (auth for 12 mos) based on adequate clinical response (annualized GR doubles).Cont tx (after AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA defects), transition adoles off somatropin 1 mo before retesting, OR 3 or more pituitary hormone deficiencies (TSH, ACTH, LH/FSH, or AVP) AND serum IGF-1 84 microg/L or less using the Esoterix ECB RIA or age/gender adjusted serum IGF-1 SDS below the 2.5 percentile.TS start, female and has short stature (SS).SHOX start, open 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 205
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2013 Prior Authorization Drug Requirements - CCHP

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