Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

Ribavirin in combination with pegylated interferon

Criteria

Approval Period

Treatment of chronic hepatitis C genotype 2, 3, 4, 5 or 6 in patients who have not been previously treated; lab work required.

Note: For treatment of chronic hepatitis C genotype 1, please see Limited Coverage criteria for boceprevir and boceprevir in combination with peginterferon/ribavirin.

First approval: 14 or 24 weeks according to genotype and drug requested.

Renewals: According to established protocols for the specific drug product as noted on the request forms.

For requests that do not meet established criteria, exceptional cases may be considered where the physician provides additional documentation of disease progression (e.g., liver biopsy or ultrasound results, etc.) and/or other
patient-specific considerations. These exceptional case submissions will be reviewed by the Hepatitis Drug Benefit Adjudication Advisory Committee.

Pegylated Interferon/Ribavirin Coverage ^(PDF)
Click on the link to complete the Pegylated Interferon/Ribavirin Coverage special authority request form.