Product Details

Glycopyrrolate Injection USP

Glycopyrrolate
4 mg/20 mL
Solution for Injection (with Preservative)


DIN/PIN/NPN

02473887

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
02473887 Glycopyrrolate Injection USP 2.7825 2.7825
09858164 Robinul NA NA
 

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.

 

EAP Criteria

NO

Product Monograph

View Monograph