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 REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA tried at least 1 other therapy. For topical adapalene products (examples include Differin gel, Differin cream, etc. and generic adapalene products), approval for the treatment of other noncosmetic conditions (eg, dermatitis/ecze ma, folliculitis, milia, keratosis pilaris, sebaceous hyperplasia/cyst, basal cell carcinoma [skin cancer], 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 218
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 confluent and reticulated papillomatosis, Darier's disease, molluscum contagiosum) can be made if the patient has tried at least 1 other therapy. Coverage of the combination clindamycin plus tretinoin product (Ziana) and the combination adapalene plus benzoyl peroxide product (Epiduo) is recommended for acne vulgaris ONLY and all other indications 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 219
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2013 Prior Authorization Drug Requirements - CCHP

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