Alfa Interferons Pegylated
| Covered Uses: | All FDA approved indications not otherwise excluded from Part D. |
| Exclusion Criteria: | For chronic hepatitis C: contraindications such as decompensated liver disease or is using in combination with another Interferon product. |
| Required Medical Information: | Coverage for chronic hepatitis C is provided in the presence of a quantifiable viral level, that is a detectable Hep C RNA viral level. |
| Age Restrictions: | |
| Prescriber Restrictions: | |
| Coverage Duration: | 12 months |
| Other Criteria: |
Last Modified on 12/19/2012