Limited Coverage Drugs - Ribavirin

Generic Name:

ribavirin (Ibavyr™)

Strength:

200 mg, 400 mg, 600 mg

Form:

tablet

Special Authority Criteria

Approval Period

For the treatment of chronic hepatitis C when used in an approved combination therapy regimen according to specific eligibility criteria.

AND

Drug is prescribed by a hepatologist, a gastroenterologist, an infectious disease specialist or another physician experienced in treating hepatitis C.

12, 16 or 24 weeks

Practitioner Exemptions

  • N/A

Special Notes

Special Authority Request Form(s)

  • For the appropriate Special Authority request form, please see Limited Coverage criteria page for the drug to be used in combination with ribavirin (see list under “Special Notes” above).