Product Details
Xenical
Orlistat120 mg
Capsule
DIN/PIN/NPN
02240325
Manufacturer
Xediton Pharmaceuticals Inc.
Formulary Listing Date
2016-04-29
Unit Price
1.6574
Amount MOH Pays
1.6574
Coverage Status
Exceptional Access Program Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
A08AB01
Interchangeable Products
NOLU Clinical Criteria
NOEAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Antidiabetic Agents | Orlistat
For the treatment of type 2 diabetes in a patient with:
*Note: Maximal dose of sulfonylurea is considered to be glyburide 10mg/day, gliclazide 160mg/day (or Diamicron MR 60 mg/day), OR glimepiride (Amaryl) 4mg/day. Duration of Approval: 1 year Renewals will be considered for those with demonstrated response to treatment reported as at least 5% weight loss and improvement in glycemic control (i.e., HbA1c less than 7.0% or HbA1c reduction of more than 0.5%) Duration of Approval: 12 months (First Renewal) EAP Drug Request Form: |