Limited Coverage Drugs - Interferon Alfa

Generic Name interferon alfa-2B (Intron A®)
Strength

10,000,000 IU/vial
6,000,000 IU/mL
10,000,000 IU/mL
15,000,000 IU/mL
25,000,000 IU/mL
50,000,000 IU/mL

Form subcutaneous injection

Special Authority Criteria

Approval Period

For the diagnosis of chronic hepatitis B, non-cirrhosis, according to established protocols. Lab work is required.

First approval: 24 weeks

One Renewal: Up to 24 weeks, only if patient demonstrates a positive response to treatment

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)