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 |