Product Details
Mint-Entecavir
Entecavir0.5 mg
Tablet
DIN/PIN/NPN
02485907
Manufacturer
Mint Pharmaceuticals Inc.
Formulary Listing Date
2020-03-31
Unit Price
5.5000
Amount MOH Pays
4.4000
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
J05AF10
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02430576 | PMS-Entecavir | 5.5000 | 4.4000 |
| 02485907 | Mint-Entecavir | 5.5000 | 4.4000 |
| 02467232 | Jamp-Entecavir | 5.5000 | 4.4000 |
| 02282224 | Baraclude | 22.6600 | 4.4000 |
| 02448777 | Auro-Entecavir | 5.5000 | 4.4000 |
| 02396955 | Apo-Entecavir | 5.5000 | 4.4000 |
| 02479907 | Accel-Entecavir | 4.4000 | 4.4000 |
| 02527154 | Entecavir | 5.5000 | 4.4000 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 505 | 1 year | Confirmed chronic Hepatitis B infection in persons with - HBV DNA greater than or equal to 1000 IU/mL AND - ALT levels greater than ULN OR - Evidence of fibrosis OR - Documented evidence of cirrhosis |
| 506 | 1 year | For patients with chronic Hepatitis B infection who have a contraindication, intolerance or inadequate response to one or more of the following: lamivudine, tenofovir, adefovir or telbivudine. |
| 507 | 1 year | Patients with chronic Hepatitis B infection currently receiving treatment with entecavir and requires treatment continuation. |
| 508 | 1 year | Patients with chronic Hepatitis B infection who are scheduled to undergo chemotherapy or significant immunosuppressive treatment. |