Limited coverage criteria – valganciclovir

 

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Generic name	valganciclovir
Strength & form	450 mg, 50 mg / mL oral tablet, oral  solution

Special Authority criteria

Approval period

For the prophylaxis of cytomegalovirus (CMV) infection post stem cell transplant, in patients who test positive for CMV upon polymerase chain reaction (PCR) laboratory testing Notes: The covered induction regimen is valganciclovir 900 mg orally twice daily for 5 days, followed by a maintenance regimen of 900 mg orally once daily for at least two 2 weeks. Valganciclovir should be dose-adjusted according to renal function

Approval lasts until there are 2 consecutive negative CMV PCR results obtained 1 week apart

Practitioner exemptions

• PharmaCare coverage is only available for patients who meet the limited coverage criteria and whose prescription has been written by a specialist physician with the leukemia/bone marrow transplant (BMT) Program at Vancouver General Hospital who has entered into a Collaborative Prescribing Agreement (CPA). As exempted practitioners, they do not need to submit Special Authority requests to receive coverage for their patients
• Due to the individual nature of each CPA, the agreement must be signed by the specialist physician who is requesting coverage and not a delegate
• Prescriptions written by other specialists who have not entered into a CPA will not be covered automatically and a Special Authority request is required

Special notes

• None

Special Authority request form(s)

• Log in to eForms
• HLTH 5328 – General Special Authority request (PDF, 656KB)