2013 Prior Authorization Drug Requirements - CCHP

FORMULARY
DRUG
BRAND NAME
generic name
ELOXATIN
INJ 2
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
depending
upon the
circumstances.
Information
may need to
be submitted
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 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
63
OTHER
CRITERIA