Limited Use Note(s)

ENTECAVIR0.5mg Tab
Reason For Use CodeClinical Criteria
505Confirmed 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
506For patients with chronic Hepatitis B infection who have a contraindication, intolerance or inadequate response to one or more of the following: lamivudine, tenofovir, adefovir or telbivudine.
LU Authorization Period: 1 year
507Patients with chronic Hepatitis B infection currently receiving treatment with entecavir and requires treatment continuation.
LU Authorization Period: 1 year
508Patients with chronic Hepatitis B infection who are scheduled to undergo chemotherapy or significant immunosuppressive treatment.
LU Authorization Period: 1 year