2013 Prior Authorization Drug Requirements - CCHP
2013 Prior Authorization Drug Requirements - CCHP
2013 Prior Authorization Drug Requirements - CCHP
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<strong>CCHP</strong> Senior Select Program (HMO SNP)<br />
<strong>2013</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Drug</strong> <strong>Requirements</strong><br />
Last Updated 04/01/<strong>2013</strong><br />
FORMULARY<br />
DRUG<br />
BRAND NAME<br />
generic name<br />
DRUG<br />
TIER<br />
LEVEL<br />
COVERED<br />
USES<br />
cerebral palsy,<br />
stroke, brain<br />
injury, spinal<br />
cord injury,<br />
MS,<br />
hemifacial<br />
spasm).<br />
Essential<br />
tremor.<br />
Dystonia other<br />
than cervical<br />
(eg, focal<br />
dystonias,<br />
tardive<br />
dystonia,<br />
anismus).<br />
Bladder/voidin<br />
g/urethral<br />
dysfunction.<br />
Frey's<br />
syndrome<br />
(gustatory<br />
sweating).<br />
Ophthalmic<br />
disorders (eg,<br />
esotropia,<br />
EXCLUSION<br />
CRITERIA<br />
REQUIRED<br />
MEDICAL<br />
INFORMATION<br />
AGE<br />
RESTRICTION<br />
PRESCRIBER<br />
RESTRICTION<br />
COVERAGE<br />
DURATION<br />
OTHER<br />
CRITERIA<br />
muscle<br />
relaxants,<br />
opioids,<br />
antidepressants)<br />
and if being<br />
used as part of a<br />
multimodal<br />
therapeutic pain<br />
management<br />
program.<br />
Tinnitus after a<br />
trial with at least<br />
2 other<br />
pharmacologic<br />
therapies (eg,<br />
lidocaine,<br />
antihistamines,<br />
antidepressants,<br />
anxiolytics,<br />
diuretics,<br />
anticonvulsants,<br />
antispastics) and<br />
tinnitus<br />
retraining<br />
therapy.<br />
Headache (eg,<br />
<strong>CCHP</strong> Senior Select Program (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.<br />
H0571_<strong>2013</strong>_142_FINAL_2 Approved 11282012<br />
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