Product Details
Mint-Levetiracetam Solution
Levetiracetam100 mg/mL
Oral Solution
DIN/PIN/NPN
02558416
Manufacturer
Mint Pharmaceuticals Inc.
Formulary Listing Date
2025-10-31
Unit Price
0.4071
Amount MOH Pays
0.4071
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N03AX14
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02490447 | PDP-Levetiracetam | 0.8142 | 0.4071 |
| 02558416 | Mint-Levetiracetam Solution | 0.4071 | 0.4071 |
| 02515318 | Pharma-Levetiracetam | 0.4071 | 0.4071 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 640 | 1 year | For patients unable to swallow or tolerate oral solid dosage forms and who are using this as adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. |
| 705 | 1 year | As adjunctive therapy in the treatment of seizure disorders in pediatric patients (less than 18 years of age) where control by other listed anticonvulsants has been unsatisfactory and where the appropriate dose cannot be achieved using listed solid oral levetiracetam dosage formats. |
Requirements