Limited Use Note(s)

TENOFOVIR DISOPROXIL300mg Tab
Reason For Use CodeClinical Criteria
517Confirmed chronic Hepatitis B infection in persons with - HBV DNA greater than or equal to 1000 IU/mL AND - ALT levels greater than ULN OR - Evidence of fibrosis OR - Documented evidence of cirrhosis
LU Authorization Period: 1 year
518For patients with chronic Hepatitis B infection who have a contraindication, intolerance or inadequate response to one or more of the following: lamivudine, entecavir, adefovir or telbivudine.
LU Authorization Period: 1 year
519Patient is pregnant (2nd trimester or later) with HBV DNA greater than 1,000,000 IU/mL.
LU Authorization Period: 1 year
520Patients with chronic Hepatitis B infection currently receiving treatment with tenofovir and requires treatment continuation.
LU Authorization Period: 1 year
521Patients with chronic Hepatitis B infection who are scheduled to undergo chemotherapy or significant immunosuppressive treatment.
LU Authorization Period: 1 year
522For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access to HIV/AIDS Drug Products mechanism.
LU Authorization Period: 1 year