2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name XEOMIN INJ. 2 DRUG TIER LEVEL COVERED USES hyperkinetic dystonia. Hemiballism. All FDAapproved indications not otherwise excluded from Part D. Plus Achalasia. Anal Fissure. BPH. Chronic facial pain/pain associated with TMJ dysfunction. Chronic low back pain. Headache (migraine, chronic CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION Use in the management of cosmetic uses (eg, facial rhytides, frown lines, glabellar wrinkling, horizontal neck rhytides, mid and lower face and neck rejuvenation, platsymal bands, rejuvenation of the peri-orbital region), allergic rhinitis, gait freezing in Parkinsons N/A N/A AGE RESTRICTION PRESCRIBER RESTRICTION with a neurologist. For TD, Xenazine must be prescribed by or after consultation with a neurologist or psychiatrist. COVERAGE DURATION Tinnitus if prescribed by ENT. Headache if Authorization prescribed by, or will be for 12 after consultation months, unless with, a neurologist otherwise or HA specialist. 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 244 OTHER CRITERIA Primary axillary hyperhydrosis after trial with at least 1 topical agent (eg, aluminum chloride). BPH after trial with at least 2 other therapies (eg, alpha1-blocker, 5 alphareductase inhibitor, TURP, transurethral microwave heat treatment, TUNA,
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 tension HA, whiplash, chronic daily HA). Palmar/plantar and facial hyperhidrosis. Myofascial pain. Salivary hypersecretion . Spasticity (eg, due to cerebral palsy, stroke, brain injury, spinal cord injury, MS, hemifacial spasm). Essential tremor. Dystonia other than cervical (eg, focal dystonias, tardive EXCLUSION CRITERIA disease, vaginismus, interstitial cystitis, or Crocodile tears syndrome. REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA interstitial laser therapy, stents, various forms of surgery). Chronic low back pain after trial with at least 2 other pharmacologic therapies (eg, NSAID, antispasmodics, muscle relaxants, opioids, antidepressants) and if being used as part of a multimodal therapeutic pain management program. Tinnitus after a trial with at least 2 other pharmacologic 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 245
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2013 Prior Authorization Drug Requirements - CCHP

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