Product Details
Jamp Midodrine
Midodrine HCl5 mg
Tablet
DIN/PIN/NPN
02517728
Manufacturer
Jamp Pharma Corporation
Formulary Listing Date
2022-04-29
Unit Price
0.1921
Amount MOH Pays
0.1921
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
C01CA17
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02473992 | Mar-Midodrine | 0.1921 | 0.1921 |
| 02278685 | Apo-Midodrine | 0.1921 | 0.1921 |
| 01934406 | Amatine | NA | NA |
| 02517728 | Jamp Midodrine | 0.1921 | 0.1921 |
| 02533219 | Midodrine | 0.1921 | 0.1921 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 1 | Indefinite | For the treatment of patients disabled by moderate to severe neurogenic orthostatic hypotension (i.e., drop in systolic BP less than or equal to 20mm Hg from supine to standing position), in whom conventional nonpharmacologic and pharmacologic (i.e., fludrocortisone) therapies have proven ineffective or are poorly tolerated. |