2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name TYZEKA TAB 2 UVADEX SOLN 2 DRUG TIER LEVEL COVERED USES 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. N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION Requires failure of Hepsera, Baraclude or Viread. N/A N/A PRESCRIBER RESTRICTION COVERAGE DURATION Approved for duration of contract year subject to formulary change and member eligibility. N/A This drug may be covered under 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 228 OTHER CRITERIA CD criteria of treatment with corticosteroids (systemic) are allowed if steroids are contraindicated or not desired, then azathioprine, 6- mercaptopurine, or methotrexate must be tried if they are not contraindicated.
FORMULARY DRUG BRAND NAME generic name vancomycin inj. 1 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 AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION 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. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting 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 229 OTHER CRITERIA
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2013 Prior Authorization Drug Requirements - CCHP

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