Hepatitis B

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
lamivudine EPIVIR HBV SOLUTION Y PA Document  
lamivudine LAMIVUDINE HBV TABLET Y PA Document  
lamivudine LAMIVUDINE TABLET Y PA Document  
lamivudine EPIVIR HBV TABLET Y PA Document  
tenofovir disoproxil fumarate VIREAD TABLET Y PA Document  
tenofovir disoproxil fumarate TENOFOVIR DISOPROXIL FUMARATE TABLET Y PA Document  
adefovir dipivoxil HEPSERA TABLET N PA Document  
adefovir dipivoxil ADEFOVIR DIPIVOXIL TABLET N PA Document  
entecavir BARACLUDE SOLUTION N PA Document  
entecavir BARACLUDE TABLET N PA Document  
entecavir ENTECAVIR TABLET N PA Document  
tenofovir alafenamide fumarate VEMLIDY TABLET N PA Document  
tenofovir disoproxil fumarate VIREAD POWDER N PA Document