Generic Name / Strength / Form

interferon alfa

Criteria	Approval Period
1. Diagnosis of chronic Hepatitis B, non-cirrhosis. According to established protocols; lab work required. Submit Hepatitis B requests using the Chronic Hepatitis B form. See form link below.	1. First approval: 24 weeks One Renewal: Up to 24 weeks, only if patient demonstrates a positive response to treatment.
OR
2. Treatment of chronic Hepatitis C according to established protocols (similar eligibility criteria as for interferon / ribavirin combination therapy). Submit Hepatitis C requests on the Pegylated Interferon/Ribavirin Coverage form. See form link below. Please clearly indicate coverage request is for interferon.	2. First approval: Sixteen weeks Renewals: Thirty-six weeks, only if patient demonstrates a positive response to treatment, defined as a negative PCR.

Practitioner Exemptions

• No practitioner exemptions

Special Notes

• None

Forms

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

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

PDF Format

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Last Revised: March 20, 2008