Limited Coverage Drugs - Entecavir

Generic Name / Strength / Form

entecavir / 0.5 mg / tablet

Special Authority Criteria

Approval Period

Diagnosis of chronic hepatitis B

PLUS

  1. Provide histologic or radiologic evidence of cirrhosis

    OR

    Provide other evidence of portal hypertension

PLUS

  1. Lab work required as per 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)