2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name EXTAVIA INJ. 2 fentanyl lollipop 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 describing the use and setting of the drug to make the determination. All FDAapproved indications not otherwise excluded from Part D. N/A N/A N/A All FDAapproved indications not otherwise excluded from Part D. N/A N/A N/A AGE RESTRICTION PRESCRIBER RESTRICTION Prescribed by or after consultation with a neurologist or an MS specialist. COVERAGE DURATION Authorization will be for 12 months, unless otherwise specified. For breakthrough Authorization chronic pain, will be for 12 prescriber is a pain months, unless management otherwise specialist. specified. 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 76 OTHER CRITERIA N/A For breakthrough pain in patients with cancer and for breakthrough chronic (noncancer) pain, if patient is unable to swallow, has dysphagia, esophagitis, mucositis, or uncontrollable nausea/vomiting OR patient is
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 unable to take 2 other shortacting narcotics (eg, oxycodone, morphine sulfate, hydromorphone, etc) secondary to allergy or severe adverse events AND patient is on or will be on a long-acting narcotic (eg, Duragesic), or the patient is on intravenous, subcutaneous, or spinal (intrathecal, epidural) narcotics (eg, morphine sulfate, hydromorphone, 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 77
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2013 Prior Authorization Drug Requirements - CCHP

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