Product Details
Jamp Teriflunomide
Teriflunomide14 mg
Tablet
DIN/PIN/NPN
02504170
Manufacturer
Jamp Pharma Corporation
Formulary Listing Date
2022-07-29
Unit Price
14.9300
Amount MOH Pays
14.9300
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
L04AA31
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
02502933 | Ach-Teriflunomide | 14.9300 | 14.9300 |
02500639 | Apo-Teriflunomide | 14.9300 | 14.9300 |
02416328 | Aubagio | 60.2464 | 14.9300 |
02504170 | Jamp Teriflunomide | 14.9300 | 14.9300 |
02523833 | M-Teriflunomide | 14.9300 | 14.9300 |
02500469 | Mar-Teriflunomide | 14.9300 | 14.9300 |
02500310 | Nat-Teriflunomide | 14.9300 | 14.9300 |
02500434 | PMS-Teriflunomide | 14.9300 | 14.9300 |
02505843 | Sandoz Teriflunomide | 14.9300 | 14.9300 |
02501090 | Teva-Teriflunomide | 14.9300 | 14.9300 |
LU Clinical Criteria
LU Code | Auth. Period | Clinical Criteria |
---|---|---|
647 | 1 year | For the treatment of Relapsing Remitting Multiple Sclerosis (RRMS) in adult patients with active disease meeting ALL the following criteria: 1. 18 years of age or older; AND 2. Diagnosis of RRMS is in accordance with the McDonald 2017 criteria demonstrating dissemination of lesions in the central nervous system in space and time meeting the following: - 2 or more attacks (Note 1) and clinical evidence of 2 or more lesions (Note 2); OR - 2 or more attacks and clinical evidence of 1 lesion with clear historical evidence of a prior attack involving a lesion in a different location; Note 1: If the patient has experienced only one attack, the patient must meet ONE of the additional criteria of dissemination in time in the list below: - Additional clinical attack Note 2: If the patient has evidence of only one lesion the patient must meet ONE of the additional criteria of dissemination in space in the list below: - additional clinical attack implicating different CNS site AND 3. Patient has experienced a clinical relapse and/or new MS lesions in the last 2 years; AND 4. Patient has an Expanded Disability Status Scale (EDSS) score less than 6.0 before start of therapy; AND 5. Teriflunomide is used as monotherapy; AND 6. The drug request is from a neurologist experienced in the management of RRMS. Exclusion Criteria: 1. Combination therapy with another disease modifying therapy for RRMS will not be reimbursed.
Teriflunomide may be continued for the treatment of RRMS for patients who have not experienced a suboptimal response with teriflunomide monotherapy and who have an EDSS score less than 7.0. Patients who continue to experience clinical attacks or increased lesions or worsening EDSS should be evaluated for appropriateness of therapy and consideration of other treatment options available on the ODB formulary or through the Exceptional Access Program. Renewal duration: 1 year Recommended Dose: 14mg once daily Refer to the product monograph for prescribing information. |
EAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Renewals of Multiple Sclerosis Drugs – Telephone Request Service (TRS) Drugs | Teriflunomide
EAP will renew coverage of teriflunomide for patients who are stable and experienced no more than one disabling attack/relapse in the past year and have an EDSS score less than or equal to 5. Prescriber must provide the following information:
Dosage: 14 mg daily Standard Approval Duration: 2 years for first renewal, 5 years for 2nd and subsequent renewals Renewal requests where patients have experienced more than 1 attack in the past year will be externally reviewed. |