Hepatitis B

← Back to Class List

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  
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