Product Details
Apo-Eltrombopag
Eltrombopag Olamine25 mg
Tablet
DIN/PIN/NPN
02506742
Manufacturer
Apotex Inc.
Formulary Listing Date
2023-07-31
Unit Price
55.2500
Amount MOH Pays
55.2500
Coverage Status
Off-Formulary Interchangeable Exceptional Access Program Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
B02BX05
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02506742 | Apo-Eltrombopag | 55.2500 | 55.2500 |
| 02361825 | Revolade | 65.0000 | 55.2500 |
LU Clinical Criteria
NOEAP Criteria
| Therapeutic Class | Reimbursement Criteria |
|---|---|
| Blood Modifiers | Eltrombopag
For the treatment of refractory chronic idiopathic thrombocytopenic purpura (ITP) with bleeding complications in patients who meet the following criteria:
1Requests for Revolade where the requesting physician has stated that the patient is not a candidate for splenectomy will be assessed on a case-by-case basis. The requesting physician must provide rationale for why a splenectomy cannot be considered, and where possible, to include a preoperative/surgical evaluation on the patient’s surgical risks to splenectomy, to include consideration of risks of laparoscopic and open surgical interventions if these are available. This evaluation must come from a physician who is not the requesting physician. 2Appropriate first-line treatment modalities may include:
2Appropriate second-line treatment modalities include:
Note: Patients need to have failed at least two of the second-line therapies listed above prior to requesting Revolade. Dosage: 50 mg once daily to a maximum of 75 mg once daily. Duration of Approval: 1 year Renewal of requests for Revolade will be assessed on a case-by-case basis Note: Revolade therapy beyond 1 year of continuous treatment has not been studied. After 1 year of continuous treatment, therapeutic options should be reassessed. |