Limited Coverage Drugs - Ribavirin

 Effective March 23, 2017, PharmaCare will no longer approve new requests for coverage of Holkira Pak.

Generic Name:

Ribavirin (Moderiba™)

Strength:

200 mg, 400 mg, 600 mg

Form:

tablet

Special Authority Criteria

Approval Period

For treatment of chronic hepatitis C genotype 1 when used in combination with ombitasvir-paritaprevir-ritonavir and dasabuvir. 

Please see Limited Coverage criteria for ombitasvir-paritaprevir-ritonavir and dasabuvir

12 or 24 weeks

Practitioner Exemptions

  • N/A

Special Notes

  • N/A

Special Authority Request Form(s)

  • N/A