Interactive Drug Benefit List
DIN/NPN/PIN 02439212 IBAVYR 200 MG ORAL TABLET RIBAVIRIN
080000 ANTI-INFECTIVE AGENTS
081800 ANTIVIRALS
081832 NUCLEOSIDES AND NUCLEOTIDES
Date Listed/Coverage Update: 01-Dec-2015
Unit Price: 12.2399
LCA Price: N/A
MAC Price:

N/A

Unit of Issue: Tablet
Manufacturer: PENDOPHARM INC. (PPH)
ATC: J05AB04
1
Interchangeable Products: No

Coverage Status: SPECIAL AUTHORIZATION
Applies to Clients of: Non-Group Coverage (Group 1)
Coverage for Seniors (Group 66)
Palliative Coverage (Group 20514, Please note your client may have Group 1 or Group 66 coverage)
Child and Family Services (Group 20403)
Alberta Child Health Benefit (Group 20400)
Children and Youth Services (Group 19824)
Income Support (Group 19823)
Alberta Human Services (AISH) (Group 19823)
Alberta Adult Health Benefit (AAHB) (Group 23609)

Special Authorization Request Form:

Sofosbuvir/Velpatasvir for Chronic Hepatitis C Special Authorization Request Form (ABC 60100)

Sofosbuvir/Ledipasvir for Chronic Hepatitis C Special Authorization Request Form (ABC 60101)

Sofosbuvir for Chronic Hepatitis C Special Authorization Request Form (ABC 60103)

SPECIAL AUTHORIZATION

For use within an Alberta Drug Benefit List (ADBL) funded combination therapy regimen for the treatment of chronic hepatitis C according to specific eligibility criteria corresponding to the regimen in which it is being administered. Use of ribavirin outside of an ADBL hepatitis C funded regimen will not be reimbursed.

(Refer to Section 3 of the Alberta Drug Benefit List for specific eligibility criteria corresponding to the regimen in which ribavirin is being administered for the treatment of Chronic Hepatitis C.)

Review Status / Past Decisions

Indication Reviewing
Body
Submission
Completion
Date
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation
Review
Status
N/A Expert Committee 2015/06/02 2015/09/01 Under Review
N/A Expert Committee 2015/06/02 2015/11/01 Under Review
N/A Expert Committee 2015/06/02 2015/12/01 Special Authorization
N/A Expert Committee 2015/06/02 2017/04/01 Special Authorization Criteria Change
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2015/06/02
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2015/09/01
CDR
Recommendation
Review
Status
Under Review
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2015/06/02
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2015/11/01
CDR
Recommendation
Review
Status
Under Review
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2015/06/02
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2015/12/01
CDR
Recommendation
Review
Status
Special Authorization
Indication N/A
Reviewing
Body
Expert Committee
Submission
Completion
Date
2015/06/02
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date
2017/04/01
CDR
Recommendation
Review
Status
Special Authorization Criteria Change
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Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.
Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL(iDBL), and any such changes to the Interactive DBL(iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.