Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
entecavir 0.5mg tablet

Criteria Approval Period
Diagnosis of chronic Hepatitis B

PLUS

Provide histologic or radiologic evidence of cirrhosis
OR
Provide other evidence of portal hypertension

PLUS

Lab work required as per 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 entecavir 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.