Product Details
Mycobutin
Rifabutin150 mg
Capsule
DIN/PIN/NPN
02063786
Manufacturer
Pfizer Canada Inc.
Formulary Listing Date
1996-10-01
Unit Price
6.2161
Amount MOH Pays
6.2161
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
J04AB04
Interchangeable Products
NOLU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 103 | 1 year | For the prevention of Mycobacterium Avium Intracellular (MAI) in: Patients with a CD4+ cell count less than 200/mm3 with an AIDS-defining diagnosis; |
| 104 | 1 year | For the prevention of Mycobacterium Avium Intracellular (MAI) in: Patients with a CD4+ cell count less than 100/mm3 without an AIDS-defining diagnosis. |
EAP Criteria
| Therapeutic Class | Reimbursement Criteria |
|---|---|
| Unclassified EAP Drugs | These drugs are not currently listed in the Exceptional Access Program Reimbursement Criteria for Frequently Requested Drugs – August 8, 2023 Edition Physicians may wish to contact the EAP directly by phone at 416-327-8109 or 1-866-811-9893 or by email at EAPFeedback.MOH@ontario.ca to see if an unlisted drug product and/or indication may be considered for EAP funding. |