2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name BOSULIF TAB 2 BOTOX INJ 2 DRUG TIER LEVEL COVERED USES 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. CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION All FDAapproved indications not otherwise excluded from Part D. N/A N/A N/A N/A All FDAapproved management of Use in the indications not cosmetic uses otherwise (eg, facial excluded from rhytides, frown N/A PRESCRIBER RESTRICTION COVERAGE DURATION Approved for duration of contract year subject to formulary change and member eligibility. Authorization 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 26 N/A Tinnitus if prescribed by ENT. will be for 12 Headache if months, unless prescribed by, or otherwise after consultation specified. OTHER CRITERIA N/A Primary axillary hyperhydrosis after trial with at least 1 topical agent (eg,
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 Part D. Plus Achalasia. Anal Fissure. BPH. Chronic facial pain/pain associated with TMJ dysfunction. Chronic low back pain. Headache (migraine, chronic tension HA, whiplash, chronic daily HA). Palmar/plantar and facial hyperhidrosis. Myofascial pain. Salivary hypersecretion . Spasticity (eg, due to EXCLUSION CRITERIA 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 disease, vaginismus, interstitial cystitis, or Crocodile tears syndrome. REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION with, a neurologist or HA specialist. COVERAGE DURATION OTHER CRITERIA aluminum chloride). BPH after trial with at least 2 other therapies (eg, alpha1-blocker, 5 alphareductase inhibitor, TURP, transurethral microwave heat treatment, TUNA, interstitial laser therapy, stents, various forms of surgery). Chronic low back pain after trial with at least 2 other pharmacologic therapies (eg, NSAID, antispasmodics, 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 27
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2013 Prior Authorization Drug Requirements - CCHP

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