Product Details
Apo-Brivaracetam
Brivaracetam25 mg
Tablet
DIN/PIN/NPN
02538687
Manufacturer
Apotex Inc.
Formulary Listing Date
2024-11-29
Unit Price
3.2400
Amount MOH Pays
3.2400
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N03AX23
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02452944 | Brivlera | 4.3200 | 3.2400 |
| 02538687 | Apo-Brivaracetam | 3.2400 | 3.2400 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 548 | Indefinite | - As adjunctive therapy in the treatment of patients with partial-onset seizures (POS) who have had an inadequate response or have significant intolerance to at least 2 other less costly anticonvulsant therapies (prior or current use); AND - Patients are not receiving concurrent therapy with levetiracetam; AND - Patients are under the care of a physician experienced in the treatment of epilepsy. Note: Less costly anticonvulsant therapies may include the following: Phenytoin, carbamazepine, gabapentin, lamotrigine, vigabatrin, topiramate, etc. |