Product Details

PDP-Levetiracetam

Levetiracetam
100 mg/mL
Oral Solution


DIN/PIN/NPN

02490447

Manufacturer

Pendopharm, Division of Pharmascience Inc.

Formulary Listing Date

2022-12-21  

Unit Price

0.8142

Amount MOH Pays

0.8142

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N03AX14

Interchangeable Products

NO  

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
640 1 year

For patients unable to swallow or tolerate oral solid dosage forms and who are using this as adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory.

705 1 year

As adjunctive therapy in the treatment of seizure disorders in pediatric patients (less than 18 years of age) where control by other listed anticonvulsants has been unsatisfactory and where the appropriate dose cannot be achieved using listed solid oral levetiracetam dosage formats.

 

EAP Criteria

NO

Product Monograph

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