Product Details
M-Levetiracetam
Levetiracetam250 mg
Tablet
DIN/PIN/NPN
02524562
Manufacturer
Mantra Pharma Inc.
Formulary Listing Date
2022-11-30
Unit Price
0.3210
Amount MOH Pays
0.3210
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N03AX14
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02461986 | Sandoz Levetiracetam | 0.3210 | 0.3210 |
| 02482274 | Riva-Levetiracetam | 0.3210 | 0.3210 |
| 02499193 | NRA-Levetiracetam | 0.3210 | 0.3210 |
| 02440202 | Nat-Levetiracetam | 0.3210 | 0.3210 |
| 02399776 | Ach-Levetiracetam | 0.3210 | 0.3210 |
| 02454653 | Levetiracetam | 0.3210 | 0.3210 |
| 02442531 | Levetiracetam | 0.3210 | 0.3210 |
| 02353342 | Levetiracetam | 0.3210 | 0.3210 |
| 02247027 | Keppra | 1.7836 | 0.3210 |
| 02403005 | Jamp-Levetiracetam | 0.3210 | 0.3210 |
| 02375249 | Auro-Levetiracetam | 0.3210 | 0.3210 |
| 02285924 | Apo-Levetiracetam | 0.3210 | 0.3210 |
| 02274183 | Act Levetiracetam | 0.3210 | 0.3210 |
| 02504553 | Jamp Levetiracetam Tablets | 0.3210 | 0.3210 |
| 02524562 | M-Levetiracetam | 0.3210 | 0.3210 |
| 02442388 | Mint-Levetiracetam | 0.3210 | 0.3210 |
| 02296101 | PMS-Levetiracetam | 0.3210 | 0.3210 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 473 | Indefinite | As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. |