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 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 patients started/stabiliz 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 242
FORMULARY DRUG BRAND NAME generic name VOTRIENT TAB 2 XENAZINE TAB 2 DRUG TIER LEVEL COVERED USES ed on intravenous (IV) or oral voriconazole for a systemic infection. CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION All FDAapproved indications not otherwise excluded from Part D. N/A N/A N/A All FDAapproved indications not otherwise excluded from Part D. Tardive dyskinesia (TD). Tourette syndrome and related tic disorders. Primary N/A N/A N/A AGE RESTRICTION PRESCRIBER RESTRICTION Requires the prescriber to be an Oncologist or be in under the direct consultation with an Oncologist. For treatment of chorea associated with Huntington's disease, Tourette syndrome or related tic disorders, primary hyperkinetic dystonia, or hemiballism, Xenazine must be prescribed by or after consultation COVERAGE DURATION Approved for duration of plan year subject to formulary change and member eligibility. 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 243 OTHER CRITERIA N/A N/A
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2013 Prior Authorization Drug Requirements - CCHP

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