Product Details
Jamp Pentoxifylline SR
Pentoxifylline400 mg
SR Tablet
DIN/PIN/NPN
02543087
Manufacturer
Jamp Pharma Corporation
Formulary Listing Date
2024-11-29
Unit Price
0.7238
Amount MOH Pays
0.7238
Coverage Status
Limited Use Product Chronic-Use Medication
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
C04AD03
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02221977 | Trental | NA | NA |
| 02230090 | Pentoxifylline SR | 0.7238 | 0.7238 |
| 02543087 | Jamp Pentoxifylline SR | 0.7238 | 0.7238 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 76 | Indefinite | For the treatment of patients with critical limb ischemia (with arterial ulcers, gangrene and/or rest pain) and documented arterial vascular disease. Note: Limited Use form must specify if arterial ulcers, gangrene and/or rest pain are present. |
| 529 | 1 year | For the treatment of patients with venous ulcers lasting, or expected to last, more than 8 weeks. Treatment should be discontinued after 3 months if there is no indication of objective benefit. The duration of therapy with pentoxifylline should not exceed 12 months. Note: Pentoxifylline should be used in combination with compression therapy. |