Limited Coverage Drugs - Adefovir

Generic Name

adefovir

Strength

10 mg
Form tablet

Special Authority Criteria

Approval Period

Diagnosis of chronic hepatitis B

PLUS

  1. Lamivudine resistance (previous use of lamivudine for minimum 3 months)

PLUS

  1. Compliance with medications

PLUS

  1. Lab work required as indicated on the chronic hepatitis B form.

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • In exceptional cases, PharmaCare may consider requests for coverage of patients who do not meet the established criteria if the physician provides additional documentation supporting the patient's specific clinical need. The Hepatitis Drug Benefit Adjudication Advisory Committee reviews exceptional case submissions.

Special Authority Request Form(s)