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 Essential tremor after a trial with at least 1 other pharmacologic therapy (eg, primidone, propranolol, benzodiazepines , gabapentin, topiramate). Bladder/Voiding /Urethral dysfunction after a trial with at least 1 other pharmacologic therapy (eg, oral antimuscarinic agents). Gastroparesis after a trial with at least 1 promotility drug (eg, metoclopramide, tegasterod, 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 30
FORMULARY DRUG BRAND NAME generic name DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA REQUIRED MEDICAL INFORMATION AGE RESTRICTION PRESCRIBER RESTRICTION COVERAGE DURATION All FDAapproved indications not otherwise excluded from Part D. All medically accepted indications not Approved for duration of contract year subject to Restricted to or in formulary BRILINTA otherwise excluded from consult with Cardiology change and member TAB 2 Part D N/A N/A N/A Specialist. eligibility. N/A budesonide susp. 1 This drug may N/A N/A N/A N/A N/A N/A 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 31 OTHER CRITERIA erythromycin). Tourette's syndrome if after a trial with at least 1 more commonly used pharmacologic therapy (eg, neuroleptics, clonidine, SSRIs, psychostimulant s).
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2013 Prior Authorization Drug Requirements - CCHP

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