2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name TRACLEER TAB 2 DRUG TIER LEVEL COVERED USES circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 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. Patients currently on Letairis or Tracleer for treatment of pulmonary arterial hypertension. N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION For the FDA-approved indication of pulmonary arterial hypertension, patients not currently on Letairis or Tracleer are required to have had a right-heart catheterization to confirm the diagnosis of PAH to ensure appropriate medical assessment. For the FDA-approved indication of pulmonary arterial hypertension, patients currently on Letairis or Tracleer may N/A AGE RESTRICTION PRESCRIBER RESTRICTION For treatment of pulmonary arterial hypertension, Letairis or Tracleer must be prescribed by or in consultation with a cardiologist or a pulmonologist. COVERAGE DURATION Authorization will be for 12 months, unless otherwise specified. 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 214 OTHER CRITERIA Digital ulcers, approve Tracleer if the patient has tried two other therapies for this condition such as calcium channel blockers (eg, amlodipine, felodipine, isradipine, nifedipine), alpha-adrenergic blockers (eg, prazosin), nitroglycerin,
FORMULARY DRUG BRAND NAME generic name TRAVASOL INJ. 2 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION continue therapy if they have a diagnosis of PAH. AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION This drug may be covered under Medicare Part B or D depending upon the circumstances. Information 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 215 OTHER CRITERIA phosphodiestera se-5 inhibitors (eg, sildenafil, vardenafil), or angiotensinconverting enzyme inhibitors (ACE inhibitors), or the patient has tried one vasodilator product (eg, intravenous epoprostenol, intravenous alprostadil).
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2013 Prior Authorization Drug Requirements - CCHP

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