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.
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.

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NDC Brand Name Generic Name Form Strength PDL
Status
Rebate Current Drug Use Criteria
82154045101 PEGASYS peginterferon alfa-2a SYRINGE 180 mcg/0.5 mL Y Y  
82154045104 PEGASYS peginterferon alfa-2a SYRINGE 180 mcg/0.5 mL Y Y  
82154044901 PEGASYS peginterferon alfa-2a VIAL 180 mcg/mL Y Y  
65862029018 RIBAVIRIN ribavirin CAPSULE 200 mg Y Y  
65862029042 RIBAVIRIN ribavirin CAPSULE 200 mg Y Y  
65862029056 RIBAVIRIN ribavirin CAPSULE 200 mg Y Y  
65862029070 RIBAVIRIN ribavirin CAPSULE 200 mg Y Y  
65862029084 RIBAVIRIN ribavirin CAPSULE 200 mg Y Y  
68382026010 RIBAVIRIN ribavirin CAPSULE 200 mg Y Y  
68382026028 RIBAVIRIN ribavirin CAPSULE 200 mg Y Y  
65862020768 RIBAVIRIN ribavirin TABLET 200 mg Y Y  
00085124101 REBETRON 1200 ribavirin/interferon alfa-2b,r KIT 1,200 mg (6 x 200 mg caps)-3 million unit/0.5 mL Y  
00085124103 REBETRON 600 ribavirin/interferon alfa-2b,r KIT 600 mg (3 x 200 mg caps)-3 million unit/0.5 mL Y