Hepatitis Management

Hepatitis Management Prior Authorization Request Form

Covered Uses

• Pegylated interferon alfa-2a, lamivudine, adefovir, entecavir, and telbivudine
  • Chronic Hepatitis B
• Peginterferon alfa-2b
  • Hepatitis C
• Peginterferon alfa-2a
  • Hepatitis C
  • Hepatitis C with HIV coinfection in patients clinically stable

Exclusion Criteria

For Hepatitis B - Transplanted patients

Required Medical Information

• For Hepatitis B (ICD-9: 070.22, 070.23, 070.32, 070.33)
  • Wild-type virus
    • HBs Ag positive for more than six months AND
    • Hbe Ag positive AND
    • HBV DNA by PCR more than 20,000 IU/mL AND
    • ALT less than or equal to 2 x ULN or ALT greater than 2 x ULN
  • Mutant virus
    • HBs Ag positive for more than six months AND
    • Hbe Ag negative AND
    • HBV DNA by PCR more than 20,000 IU/mL AND
    • ALT greater than 2 x ULN
  • Mutant virus
    • HBs Ag positive for more than six months AND
    • Hbe Ag negative AND
    • HBV DNA by PCR more than 2,000 IU/mL AND
    • ALT 1 to greater than 2 x ULN
  • Cirrhosis
    • HBs Ag positive for more than six months AND
    • Hbe Ag positive or negative AND
    • HBV DNA by PCR more than 2,000 IU/mL AND
    • Compensated cirrhosis or decompensated cirrhosis
• For Hepatitis C (ICD-9 code 070.54, 070.51)
  • First prescription accompanied by results of the genotype test and viral load test

Age Restrictions

None

Prescriber Restrictions

• Gastroenterologist
• Infectologist

Coverage Duration

• HBV orals: up to six (6) months
• PEG-IFN: genotype 1 and 4-up to 12 months; genotype 2 and 3 up to six (6) months

Other Criteria

• For Hepatitis C:
  • 3 months for patients with genotype 1 and 4
  • Additional 9 months for patients with genotype 1 and 4 and a viral load reduction of 2 or more log documented on Rx and results of a second viral load test
  • 6 months for patients with genotypes 2 and 3
• See AASLD Practice Guidelines for Chronic Hepatitis B
• See AASLD Practice Guidelines: Diagnosis, Management, and Treatment of Hepatitis C
• See Management and Treatment of Hepatitis C Viral Infection: Recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program Office