Product Details
Lacosamide
Lacosamide100 mg
Tablet
DIN/PIN/NPN
02512882
Manufacturer
Sanis Health Inc.
Formulary Listing Date
2021-11-30
Unit Price
0.8750
Amount MOH Pays
0.8750
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N03AX18
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02357623 | Vimpat | 3.5000 | 0.8750 |
| 02472910 | Teva-Lacosamide | 0.8750 | 0.8750 |
| 02474689 | Sandoz Lacosamide | 0.8750 | 0.8750 |
| 02478218 | Pharma-Lacosamide | 0.8750 | 0.8750 |
| 02499576 | NRA-Lacosamide | 0.8750 | 0.8750 |
| 02490552 | Mint-Lacosamide | 0.8750 | 0.8750 |
| 02487810 | Mar-Lacosamide | 0.8750 | 0.8750 |
| 02488396 | Jamp-Lacosamide | 0.8750 | 0.8750 |
| 02475340 | Auro-Lacosamide | 0.8750 | 0.8750 |
| 02489295 | Ach-Lacosamide | 0.8750 | 0.8750 |
| 02512882 | Lacosamide | 0.8750 | 0.8750 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 430 | Indefinite | As adjunctive therapy in the treatment of patients with partial onset seizures who have had an inadequate response or have significant intolerance to at least 3 less costly anticonvulsant therapies; AND Patients are under the care of a physician experienced in the treatment of epilepsy. Note: Less costly anticonvulsant therapies may include the following: |