Product Details
Mint-Levetiracetam
Levetiracetam750 mg
Tablet
DIN/PIN/NPN
02442418
Manufacturer
Mint Pharmaceuticals Inc.
Formulary Listing Date
2021-11-30
Unit Price
0.5416
Amount MOH Pays
0.5416
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 |
|---|---|---|---|
| 02462001 | Sandoz Levetiracetam | 0.5416 | 0.5416 |
| 02482290 | Riva-Levetiracetam | 0.5416 | 0.5416 |
| 02499215 | NRA-Levetiracetam | 0.5416 | 0.5416 |
| 02440229 | Nat-Levetiracetam | 0.5416 | 0.5416 |
| 02399792 | Ach-Levetiracetam | 0.5416 | 0.5416 |
| 02454688 | Levetiracetam | 0.5416 | 0.5416 |
| 02442566 | Levetiracetam | 0.5416 | 0.5416 |
| 02353369 | Levetiracetam | 0.5416 | 0.5416 |
| 02247029 | Keppra | 3.0089 | 0.5416 |
| 02403048 | Jamp-Levetiracetam | 0.5416 | 0.5416 |
| 02375265 | Auro-Levetiracetam | 0.5416 | 0.5416 |
| 02285940 | Apo-Levetiracetam | 0.5416 | 0.5416 |
| 02274205 | Act Levetiracetam | 0.5416 | 0.5416 |
| 02504588 | Jamp Levetiracetam Tablets | 0.5416 | 0.5416 |
| 02524589 | M-Levetiracetam | 0.5416 | 0.5416 |
| 02442418 | Mint-Levetiracetam | 0.5416 | 0.5416 |
| 02296136 | PMS-Levetiracetam | 0.5416 | 0.5416 |
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. |