2013 Prior Authorization Drug Requirements - CCHP

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FORMULARY DRUG BRAND NAME generic name hydroxyzine syrup 1 DRUG TIER LEVEL COVERED USES CCHP Senior Select Program (HMO SNP) 2013 Prior Authorization Drug Requirements Last Updated 04/01/2013 EXCLUSION CRITERIA All FDAapproved indications not otherwise excluded from Part D. N/A N/A REQUIRED MEDICAL INFORMATION AGE RESTRICTION Patients aged less than 65 years, approve. Patients aged 65 years and older, other criteria apply. N/A PRESCRIBER RESTRICTION COVERAGE DURATION Authorization will be for 12 months, unless otherwise 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 96 OTHER CRITERIA insomnia. Approve hydroxyzine hydrochloride (tablets and syrup) or hydroxyzine pamoate (capsules) if the patient has tried at least two other FDAapproved products for the management of anxiety. Approve if the patient has tried a prescription oral second generation antihistamine product (cetirizine, fexofenadine, desloratadine,
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 levocetirizine, fexofenadine/ps eudoephedrine, or desloratadine/ps eudoephedrine) for the current condition. Approve promethazine hydrochloride tablets or syrup if the patient has tried a prescription oral anti-emetic agent (ondansetron, granisetron, dolasetron, palonosetron, aprepitant) for the current condition. Approve diphenhydramin 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 97
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2013 Prior Authorization Drug Requirements - CCHP

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