Product Details
Glycopyrrolate Injection USP
Glycopyrrolate0.2 mg/mL
Solution for Injection
DIN/PIN/NPN
02473879
Manufacturer
SteriMax Inc.
Formulary Listing Date
2022-08-31
Unit Price
2.7825
Amount MOH Pays
2.7825
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
A03AB02
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02039508 | Sandoz Glycopyrrolate | 2.7825 | 2.7825 |
| 02043610 | Robinul | NA | NA |
| 02382857 | Glycopyrrolate Injection | 2.7825 | 2.7825 |
| 02473879 | Glycopyrrolate Injection USP | 2.7825 | 2.7825 |
| 02532379 | Glycopyrrolate Injection USP | 2.7825 | 2.7825 |
| 02513749 | Glycopyrrolate Injection USP | 2.7825 | 2.7825 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 481 | 1 year | For the management of patients receiving palliative care*. *Note: The patient must have a progressive life-limiting illness and require this medication for palliative purposes. |