2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name clinisol sf inj. 2 colistimethate inj. 1 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 describing the use and setting of the drug to make the determination. This drug may be covered under 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. N/A N/A N/A N/A N/A N/A This drug may be covered under Medicare Part B or D 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 44 OTHER CRITERIA
FORMULARY DRUG BRAND NAME generic name COMETRIQ PACK 2 COPAXONE KIT 2 DRUG TIER LEVEL COVERED USES 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 indications not otherwise excluded from Part D. Multiple N/A Patients with a diagnosis of multiple sclerosis (MS) or have experienced an attack and who are at risk of MS PRESCRIBER RESTRICTION COVERAGE DURATION Approved for duration of contract year subject to formulary change and member eligibility. 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 45 N/A Prescribed by or after consultation with a neurologist or an MS specialist. Authorization will be for 12 months, unless otherwise specified. OTHER CRITERIA N/A N/A
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2013 Prior Authorization Drug Requirements - CCHP

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