Hepatitis B

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PDL Reference Documents

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 Carveout
‐ Bill FFS		 Current Drug Use Criteria
42794000308 ADEFOVIR DIPIVOXIL adefovir dipivoxil TABLET 10 mg N Y N Pharmacy PA
60505394703 ADEFOVIR DIPIVOXIL adefovir dipivoxil TABLET 10 mg N Y N Pharmacy PA
00003161412 BARACLUDE entecavir SOLUTION 0.05 mg/mL N Y N Pharmacy PA
00003161112 BARACLUDE entecavir TABLET 0.5 mg Y Y N  
16714071701 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
31722083330 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
31722083390 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
42494045730 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
42806065830 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
43547043603 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
60687021625 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
60687021695 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
61442031130 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
65862084130 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
68382092006 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
69097042602 ENTECAVIR entecavir TABLET 0.5 mg Y Y N  
00003161212 BARACLUDE entecavir TABLET 1 mg Y Y N  
16714071801 ENTECAVIR entecavir TABLET 1 mg Y Y N  
31722083430 ENTECAVIR entecavir TABLET 1 mg Y Y N  
42494045830 ENTECAVIR entecavir TABLET 1 mg Y Y N  
42806065930 ENTECAVIR entecavir TABLET 1 mg Y Y N  
43547043703 ENTECAVIR entecavir TABLET 1 mg Y Y N  
65862084230 ENTECAVIR entecavir TABLET 1 mg Y Y N  
68382092106 ENTECAVIR entecavir TABLET 1 mg Y Y N  
69097042502 ENTECAVIR entecavir TABLET 1 mg Y Y N  
60505325006 LAMIVUDINE HBV lamivudine TABLET 100 mg N Y N Pharmacy PA
61958230101 VEMLIDY tenofovir alafenamide TABLET 25 mg N Y N Pharmacy PA
61958040301 VIREAD tenofovir disoproxil fumarate POWDER 40 mg/scoop (40 mg/gram) N Y N Pharmacy PA
61958040401 VIREAD tenofovir disoproxil fumarate TABLET 150 mg Y Y N  
61958040501 VIREAD tenofovir disoproxil fumarate TABLET 200 mg Y Y N  
61958040601 VIREAD tenofovir disoproxil fumarate TABLET 250 mg Y Y N  
00904682104 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
16714082001 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
31722053530 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
33342009607 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
50268075811 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
50268075812 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
62135046630 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
64380071404 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
65862042130 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
69076010503 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
69097053302 TENOFOVIR DISOPROXIL FUMARATE tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
61958040101 VIREAD tenofovir disoproxil fumarate TABLET 300 mg Y Y N  
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