Product Details
Alphagan P
Brimonidine0.15%
Ophthalmic Solution
DIN/PIN/NPN
02248151
Manufacturer
Allergan Inc.
Formulary Listing Date
2004-11-04
Unit Price
2.6017
Amount MOH Pays
1.9320
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01EA05
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
02301334 | Brimonidine P | 2.0305 | 2.0305 |
02248151 | Alphagan P | 2.6017 | 1.9320 |
LU Clinical Criteria
LU Code | Auth. Period | Clinical Criteria |
---|---|---|
171 | Indefinite | As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated |
172 | Indefinite | As second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents |
387 | Indefinite | For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g., patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective |