Limited Coverage Drugs - Tenofovir

Generic Name

tenofovir                                    

Strength

300 mg   

Form

tablet          

Special Authority Criteria

Approval Period

For the treatment of chronic hepatitis B in treatment-naïve patients, if the Special Authority request includes all required lab work (as detailed in the HLTH 5372 Chronic Hepatitis B form).

Indefinite

 

For the treatment  of chronic hepatitis B in treatment-experienced patients, when:

  1. The patient demonstrates lamivudine resistance (previous use of lamivudine for a minimum of 3 months).
    OR
    The patient is adefovir-experienced with persistent viremia AND a history of lamivudine resistance.

    AND
     
  2. The patient is medication compliant.

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 requests.

Additional Information

Special Authority Request Form