Product Details
Teva-Voriconazole
Voriconazole200 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
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: |