Hepatitis C, Other Agents
PDL Reference Documents
- Hepatitis C Direct-acting Antivirals - Jan 28, 2016
- Hepatitis C Class Update - Jan 29, 2015
- Hepatitis C Class Update - Sep 23, 2014
- Hepatitis C Readiness to Refer Assessment - Jul 31, 2014
- Hepatitis C Advisory Committee Recommendations - Jul 31, 2014
- Hepatitis C Class Update - Jul 31, 2014
- Hepatitis C Class Update - Mar 27, 2014
- Class Update: Hepatitis C - Sep 26, 2013
- Class Review: Hepatitis C Agents - Jan 26, 2012
Newsletters
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.
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 |