Hepatitis C, Other Agents

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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
PEGINTERFERON ALFA-2A PEGASYS PROCLICK PEN INJCTR Y PA Document  
PEGINTERFERON ALFA-2A PEGASYS SYRINGE Y PA Document  
PEGINTERFERON ALFA-2A PEGASYS VIAL Y PA Document  
PEGINTERFERON ALFA-2B PEGINTRON KIT Y PA Document  
RIBAVIRIN RIBASPHERE CAPSULE Y PA Document  
RIBAVIRIN RIBAVIRIN CAPSULE Y PA Document  
RIBAVIRIN MODERIBA TABLET Y PA Document  
RIBAVIRIN COPEGUS TABLET Y PA Document  
RIBAVIRIN RIBASPHERE TABLET Y PA Document  
RIBAVIRIN RIBAVIRIN TABLET Y PA Document  
RIBAVIRIN REBETOL SOLUTION N PA Document  
RIBAVIRIN MODERIBA TAB DS PK N PA Document  
RIBAVIRIN RIBASPHERE RIBAPAK TAB DS PK N PA Document