Product Details
Jamp Travoprost Z
Travoprost0.004%
Ophthalmic Solution
5-mL Pack
DIN/PIN/NPN
02548089
Manufacturer
Jamp Pharma Corporation
Formulary Listing Date
2025-07-31
Unit Price
28.7600
Amount MOH Pays
28.7600
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01EE04
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
09857332 | Travatan Z | 58.9600 | 28.7600 |
02413167 | Sandoz Travoprost | 28.7600 | 28.7600 |
02548089 | Jamp Travoprost Z | 28.7600 | 28.7600 |
LU Clinical Criteria
LU Code | Auth. Period | Clinical Criteria |
---|---|---|
171 | Indefinite | As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated |
172 | Indefinite | As second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents |
387 | Indefinite | For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g., patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective |