Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
lamivudine

Criteria Approval Period
1. Diagnosis of chronic Hepatitis B, non-cirrhosis.

According to established protocols; 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.

2. Diagnosis of chronic Hepatitis B with cirrhosis.

According to established protocols; 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

  • None

Form

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