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Xxxxxx Anti-infectives Xxxxxx (Antivirals)
16
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
FAMCICLOVIR [Famvir] FE NC DL PA X X NC PA X
gANCICLOVIR X* X* X X X X X X X X
gANCICLOVIR [Cytovene] X 1 X X PA X X X
LAMIVUDINE solution [Epivir HBV] FE X* X X X X DL 2 X PA 3 X
LAMIVUDINE tablet [Epivir HBV] FE X* X X X X DL 4 X PA 5 X
OsELTAMIVIR [Tamiflu] DL DL PA DL DL X X 6 DL*
PEgINTERFERON ALFA-2A [Pegasys] PA* DL PA* DL PA PA X X DL PA PA 7 DL PA*
PEgINTERFERON ALFA-2B [PegIntron] PA* DL PA* DL PA PA X PA 7 DL PA
RIBAVIRIN X* X* DL PA PA X X X PA X X
RIBAVIRIN [Copegus] X X PA X NC X
RIBAVIRIN [Rebetol] X X PA X NC X
RIBAVIRIN [RibaPak] X* X* DL PA PA X PA X
RIBAVIRIN [Ribasphere 400 mg,
Ribasphere 600 mg]
X* X* DL PA PA X PA X
RIBAVIRIN solution [Rebetol solution] X X* DL PA PA X X X PA8 X
RIMANTADINE X* X* X X X X X X X X*
RIMANTADINE [Flumadine] X X* PA PA X NC PA X
TELBIVUDINE [Tyzeka] X* X* X PA X DL X PA5 DL
VALgANCICLOVIR [Valcyte] X* X* X PA X X X X X*
VALACyCLOVIR X* DL* X X X X*
VALACyCLOVIR [Valtrex] FE DL PA X X X NC X X
zANAMIVIR [Relenza] DL DL PA DL PA DL X X6 DL
Anti-infectives (Cephalosporins)
CEFACLOR X* X* X X X X X X X X*
CEFACLOR sR X* X* X X X X X X PA X*
CEFADROXIL X* X* X X X X X X X9 X
CEFDINIR X* X* X X X X X X X X*
1 Not covered under pharmacy benefit; may be covered under medical benefit
2 600 ml/30 days
3 ≥601 ml/month
4 30 tabs/30 days
5 ≥31 units/month
6 See MHDL website.
7 ≥5 doses/month
8 ≥19 yrs old
9 PA required for 1 g tablet