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 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION OTHER CRITERIA at least 1 other pharmacologic therapy (eg, oral antimuscarinic agents). Gastroparesis after a trial with at least 1 promotility drug (eg, metoclopramide, tegasterod, erythromycin). Tourette's syndrome if after a trial with at least 1 more commonly used pharmacologic therapy (eg, neuroleptics, clonidine, SSRIs, psychostimulant s). 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 248
FORMULARY DRUG BRAND NAME generic name DRUG TIER LEVEL COVERED USES XOLAIR INJ. 2 All FDAapproved indications not otherwise excluded from Part D CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA N/A REQUIRED MEDICAL INFORMATION AGE RESTRICTION Moderate to severe Patients aged 12 persistent asthma, years and older. baseline IgE level of at least 30 IU/mL. For asthma, patient has a positive skin test or in vitro testing (ie, a blood test for allergen-specific IgE antibodies such as the RAST) for 1 or more perennial aeroallergens (eg, house dust mite, animal dander [dog, cat], cockroach, feathers, mold spores) and/or for 1 or more seasonal aeroallergens (grass, pollen, weeds). PRESCRIBER RESTRICTION COVERAGE DURATION Moderate to severe Authorization persistent asthma if will be for 12 prescribed by, or in months, unless consultation with otherwise an allergist, specified. immunologist, or pulmonologist. SAR/PAR if prescribed by an allergist, immunologist, or pulmonologist. EG/EE/EC, if prescribed by or in consultation with an allergist, immunologist, or gastroenterologist. 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 249 OTHER CRITERIA Moderate to severe persistent asthma must meet all criteria. Patient's asthma symptoms have not been adequately controlled by concomitant use of at least 2 months of inhaled corticosteroid and a longacting betaagonist (LABA) or LABA alternative, if LABA contraindicated or pt has intolerance then alternatives include sustained-
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2013 Prior Authorization Drug Requirements - CCHP

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