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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.
PDF Format
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Last Revised: March 25, 2008
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