2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name TYKERB TAB 2 TYSABRI INJ 2 DRUG TIER LEVEL COVERED USES Medicare Part B or D depending upon the 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 medicallyaccepted indications not otherwise excluded from Part D. N/A All FDA approved indications not otherwise N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION Diagnosis for which Tykerb is being used. For indication of breast cancer, the HER2 status must be reported. New patients with breast cancer which is HER2- positive may receive authorization for Tykerb. N/A Adults with MS. Patient has a relapsing form of MS. Adults with CD. Patient has moderately Adults AGE RESTRICTION PRESCRIBER RESTRICTION N/A MS. Prescribed by a neurologist or an MS specialist registered with the COVERAGE DURATION Authorization will be for 12 months. Authorization will be for 12 months, unless otherwise 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 224 OTHER CRITERIA For breast cancer, new patient must have HER2- positive breast cancer for approval of Tykerb. Adults with MS. Patient has a relapsing form of MS and has
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 excluded from Part D. EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION to severely active CD with evidence of inflammation (eg, elevated C-reactive protein). AGE RESTRICTION PRESCRIBER RESTRICTION TOUCH prescribing program. CD. Prescribed by a physician registered with the TOUCH program. COVERAGE DURATION specified. OTHER CRITERIA had an inadequate response to, or is unable to tolerate, therapy with at least two of the following MS medications: interferon beta- 1a (Avonex, Rebif), interferon beta- 1b (Betaseron, Extavia), glatiramer acetate (Copaxone), or fingolimod (Gilenya). Exceptions to having tried an interferon beta- 1a or -1b product (Avonex, 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 225
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2013 Prior Authorization Drug Requirements - CCHP

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