Product Details
Med-Brimonidine
Brimonidine0.2%
Ophthalmic Solution
DIN/PIN/NPN
02507811
Manufacturer
Generic Medical Partners Inc.
Formulary Listing Date
2022-03-31
Unit Price
1.1550
Amount MOH Pays
1.1550
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01EA05
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02305429 | Sandoz Brimonidine | 1.1550 | 1.1550 |
| 02246284 | PMS-Brimonidine | 1.1550 | 1.1550 |
| 02236876 | Alphagan | 3.7970 | 1.1550 |
| 02515377 | Brimonidine Tartrate Ophthalmic Solution | 1.1550 | 1.1550 |
| 02507811 | Med-Brimonidine | 1.1550 | 1.1550 |
| 02449226 | Jamp-Brimonidine | 1.1550 | 1.1550 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 171 | Indefinite | As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated |
| 172 | Indefinite | As second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents |
| 387 | Indefinite | For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g., patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective |