2013 Prior Authorization Drug Requirements - CCHP

FORMULARY
DRUG
BRAND NAME
generic name
DRUG
TIER
LEVEL
COVERED
USES
otherwise
excluded from
Part D.
CCHP Senior Select Program (HMO SNP)
2013 Prior Authorization Drug Requirements
Last Updated 04/01/2013
EXCLUSION
CRITERIA
REQUIRED
MEDICAL
INFORMATION
requires intolerance to or
failure of therapy with
methotrexate (greater
than 20mg/wk). Plaque
Psoriasis: Failure of
methotrexate at a dose of
15mg/week or failed
soriatane.
AGE
RESTRICTION
PRESCRIBER
RESTRICTION
Arthritis and
Ankylosing
Spondylitis:
Prescriber must be
a Rheumatologist.
All Plaque
Psoriasis:
Prescriber must be
a Dermatologist.
COVERAGE
DURATION
subject to
formulary
change and
member
eligibility.
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
ENGERIX-B
make the
INJ. 2 determination. N/A N/A N/A N/A N/A N/A
enoxaparin inj. 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
66
OTHER
CRITERIA
onset RA,
additional
required medical
information is
not required.