Product Details
Med-Dorzolamide
Dorzolamide HCl2%
Ophthalmic Solution
DIN/PIN/NPN
02457210
Manufacturer
Generic Medical Partners Inc.
Formulary Listing Date
2023-08-31
Unit Price
1.4757
Amount MOH Pays
1.4757
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01EC03
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02216205 | Trusopt | 5.9540 | 1.4757 |
| 02316307 | Sandoz Dorzolamide | 1.4757 | 1.4757 |
| 02453347 | Jamp-Dorzolamide | 1.4757 | 1.4757 |
| 02457210 | Med-Dorzolamide | 1.4757 | 1.4757 |
| 02522373 | Dorzolamide | 1.4757 | 1.4757 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 171 | Indefinite | As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated |
| 172 | Indefinite | As second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents |
| 387 | Indefinite | For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g., patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective |