2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name vincristine inj. 1 vinorelbine 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 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 of the drug to make the determination. N/A N/A N/A N/A N/A N/A This drug may be covered under Medicare Part B or D depending upon the circumstances. Information 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 240 OTHER CRITERIA
FORMULARY DRUG BRAND NAME generic name voriconazole tab 1 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 may need to be submitted describing the use and setting of the drug to make the determination. All FDAapproved indications not otherwise excluded from Part D worded as invasive aspergillosis, esophageal candidiasis, treatment of fungal infections caused by Scedosporium apiospermum and Fusarium spp., and treatment of N/A EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION Esophageal candidasis requires a trial of one other systemic agent (eg., fluconazole, IV amphotericin B, itraconazole). N/A N/A PRESCRIBER RESTRICTION COVERAGE DURATION Authorization will be for 12 months, unless otherwise specified. 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 241 OTHER CRITERIA For safety reasons, if there is insufficient information available to make a determination regarding coverage and the prescribing physician or representative of the physician cannot be contacted, then approve 14-day course.
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2013 Prior Authorization Drug Requirements - CCHP

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