Product Details
Sodium Thiosulfate Injection USP
Sodium Thiosulfate250 mg/mL
Solution for Injection
50-mL Vial Pack
DIN/PIN/NPN
02428393
Manufacturer
Hope Pharmaceuticals Ltd
Formulary Listing Date
2017-05-31
Unit Price
130.0000
Amount MOH Pays
130.0000
Coverage Status
Exceptional Access Program Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
V03AB06
Interchangeable Products
NOLU Clinical Criteria
NOEAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Nephrology Treatments | Sodium Thiosulfate
Approval of sodium thiosulfate for the treatment of calciphylaxis will be provided where all of the following criteria have been met: Patients with G4 or G5 chronic kidney disease; AND
Requests for patients with calciphylaxis who do not meet the above criteria will be considered on a case-by-case basis. Duration of Approval: 2 months Renewals will be considered for patients responding to treatment with improved pain control AND reduction in lesion number or size, reduction in ulcer size, or complete ulcer healing. Recommended dose: 25g three times weekly. Duration of Approval: Two months at a time until lesions are completely resolved, and for additional 2 months after complete healing. EAP Drug Request Form: |