Product Details

Teva-Voriconazole

Voriconazole
200 mg
Tablet


DIN/PIN/NPN

02396874

Manufacturer

Teva Canada Limited

Formulary Listing Date

2014-05-29  

Unit Price

13.2403

Amount MOH Pays

13.2403

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

J02AC03

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02256479 Vfend 54.2323 13.2403
02396874 Teva-Voriconazole 13.2403 13.2403
02399253 Sandoz Voriconazole 13.2403 13.2403
02525798 Jamp Voriconazole 13.2403 13.2403
 

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
399 1 year

Outpatient continuation of treatment for documented invasive aspergillosis in patients who have demonstrated a clinical response to either oral or parenteral voriconazole.

*The first prescription must be written by a physician based at the hospital where the patient was hospitalized.

Note: Limited to 3 months of reimbursement.

 

EAP Criteria

Therapeutic Class Reimbursement Criteria
Anti-Infectives

Voriconazole

  • Brand(s): VFend
  • Dosage Form/Strength: 50 mg, 200 mg tablets, 200 mg/vial injection

For the treatment of patients who have culture positive candidemia, due to Candida species, AND with documented resistance to fluconazole.

This will be for patients whose therapy is initiated in the hospital by a hospital physician and who require continuation of therapy when they are discharged as an outpatient. Oral tablets will be authorized for those with a properly functioning gastrointestinal (GI) tract and the parental injection will be authorized for those who do not have a properly functioning GI.

Case-by-case consideration for other indications will be provided.

Duration of Approval: 1 month

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph