2013 Prior Authorization Drug Requirements - CCHP

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
REQUIRED
MEDICAL
INFORMATION
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
COVERAGE
DURATION
OTHER
CRITERIA
less than 90% of
the lower limit
of ideal body wt
OR BMI less
than or equal to
20 kg/m2 AND
able to consume
or be fed via
parenteral or
enteral feedings
75% or more of
maintenance
energy
requirements
based on current
body weight
AND on
antiretroviral tx
greater than or
equal to 30 days
prior to
beginning GH tx
and will
continue
antiretroviral tx
throughout GH
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
208