Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
adefovir

Criteria Approval Period
Diagnosis of chronic Hepatitis B

PLUS

Lamivudine resistance (previous use of lamivudine for minimum 3 months)

PLUS

Compliance with medications

PLUS

Lab work required as indicated on the chronic Hepatitis B form.

 First approval: One year

Renewals: One year, only if patient demonstrates a positive response to treatment.

All requests to be submitted on the Chronic Hepatitis B form.
See form link below.

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Coverage for adefovir for chronic Hepatitis B becomes effective March 27, 2008.

Form

Chronic Hepatitis B - Initial and Renewal Coverage (PDF)
Click on the link to complete a special authority request form.