2013 Prior Authorization Drug Requirements - CCHP

More documents

Recommendations

Info

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 infection. HCV RNA at TW 4 required,TW 12 if HCV RNA less than 100=addl 12wks if HCV RNA greater or equal to 100=no addl,TW 24 if early responder with undetectable HCV RNA and pt non-black and for tx-naive pt with chronic HCV-1 monoinfection without cirrhosis=addl 4wks,TW 24 if early responder with undetectable HCV RNA and pt non-black and for retx in pt with chronic HCV-1 monoinfection previously treated for HCV with interferon/peginterferon alfa without cirrhosis=addl 12wks,TW 24 if early responder with undetectable HCV RNA AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA with peginterferon alfa and ribavirin prior to initiating boceprevir and boceprevir must be prescribed in combination as triple-drug therapy with peginterferon alfa and ribavirin. 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 234
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 and pt black=addl 24wks,TW 24 if late responder with undetectable HCV RNA and pt non-black=addl 12wks if pt black=addl 24wks,TW 24 if early or late responder with detectable HCV RNA=no addl. Retx in pts with chronic HCV-1 monoinfection previously treated with interferon/peginterferon alfa without cirrhosis null-responder documentation required,TW 12 if HCV RNA less than 100=addl 12wks if HCV RNA greater or equal to 100=no addl,TW 24 if HCV RNA undetectable=addl 24wks if HCV RNA detectable=no addl. Poor 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 235
Page 1 and 2:
FORMULARY DRUG BRAND NAME generic n
Page 3 and 4:
Page 5 and 6:
CCHP Senior Select Program (HMO SNP
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Page 117 and 118:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184: CCHP Senior Select Program (HMO SNP
Page 185 and 186: FORMULARY DRUG BRAND NAME generic n
Page 233: FORMULARY DRUG BRAND NAME generic n
Page 255: CCHP Senior Select Program (HMO SNP
show all

2013 Prior Authorization Drug Requirements - CCHP

Create successful ePaper yourself

Delete template?

Save as template?