Product Details

Mint-Tizanidine

Tizanidine HCl
4 mg
Tablet


DIN/PIN/NPN

02536765

Manufacturer

Mint Pharmaceuticals Inc.

Formulary Listing Date

2023-12-29  

Unit Price

0.8758

Amount MOH Pays

0.8758

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

Skeletal Muscle Relaxants (12:20): Muscle relaxants, other than baclofen and dantrolene sodium, are not indicated for spasticity due to cerebral palsy, multiple sclerosis, spinal cord injury, etc.

ATC Code

M03BX02

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02239170 Zanaflex NA NA
02259893 Apo-Tizanidine 0.8758 0.8758
02536765 Mint-Tizanidine 0.8758 0.8758
 

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Spasticity Treatments

Tizanidine

  • Brand(s): Zanaflex
  • Dosage Form/Strength: 4 mg tablet

For the treatment of spasticity in patients who have failed and/or cannot tolerate at least two of the following available alternatives: baclofen, diazepam and dantrolene.

Submission must describe the intolerance experienced.

Duration of Approval: Lifetime

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph