Limited Coverage Drugs - ribavirin

Generic Name

ribavirin (Ibavyr™)


200 mg, 400 mg, 600 mg




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.


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

12, 16 or 24 weeks

Practitioner Exemptions

  • None

Special Notes

Special Authority Request Form

  • 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).