Product Details

Lacri-Lube

Petrolatum + Mineral Oil
55% + 42.5%
Ophthalmic Ointment
3.5-g Tube Pack

DIN/PIN/NPN

00210889

Manufacturer

Allergan Inc.

Formulary Listing Date

1996-10-01  

Unit Price

7.1900

Amount MOH Pays

7.1900

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

S01XA20

Interchangeable Products

NO  

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
49 Indefinite

For patients with objective evidence of keratoconjunctivitis sicca as confirmed by filamentary keratopathy on slit lamp examination or biopsy.
 

EAP Criteria

NO

Product Monograph

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