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 spp., and treatment of candidemia in nonneutropeni c patients and the following Candida infections: disseminated infections in skin and infections in the abdomen, kidney, bladder wall, and wounds, treatment/prev ention of other serious systemic or suspected systemic fungal infections. Continuation therapy for EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA 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 232
FORMULARY DRUG BRAND NAME generic name VICTOZA INJ. 2 VICTRELIS CAP 2 DRUG TIER LEVEL COVERED USES patients started/stabiliz ed on intravenous (IV) or oral voriconazole for a systemic infection. All FDAapproved indications not otherwise excluded from CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION Part D. N/A N/A N/A N/A All FDAapprovenanve HCV RNA titers.Tx- pts with chronic indications not HCV-1 monoinfection otherwise without cirrhosis and excluded from retx of pts with chronic Part D. Plus HCV-1 monoinfection adult patients who have been with Hepatitis previously treated with B virus interferon/peginterferon (HBV)/chroni alfa without c HCV cirrhosis,greater or equal genotype 1 co-N/A to 1 log10 reduction in Adults PRESCRIBER RESTRICTION All FDA-approved indications. Prescribed by or in consultation with a gastroenterologist or infectious disease physician. COVERAGE DURATION Authorization will be for 12 months, unless otherwise specified. FDA-approved indications,auth orization=8wks withTW 12, 24 assessment.Othr =12mo. 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 233 OTHER CRITERIA N/A HCV RNA titers not available but sent approve until available. For all FDAapproved indications, patient must have completed or will be completing a 4- week lead-in
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2013 Prior Authorization Drug Requirements - CCHP

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