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 Class Update - Jul 31, 2014
- Hepatitis C Advisory Committee Recommendations - Jul 31, 2014
- Hepatitis C Readiness to Refer Assessment - 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.
Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation & Updates |
---|---|---|---|---|---|
peginterferon alfa-2a | PEGASYS | SYRINGE | Y | ||
peginterferon alfa-2a | PEGASYS | VIAL | Y | ||
ribavirin | RIBAVIRIN | CAPSULE | Y | ||
ribavirin | RIBAVIRIN | TABLET | Y | ||
ribavirin/interferon alfa-2b,r | REBETRON 1200 | KIT | |||
ribavirin/interferon alfa-2b,r | REBETRON 600 | KIT |