Product Details
Mint-Lacosamide
Lacosamide200 mg
Tablet
DIN/PIN/NPN
02490579
Manufacturer
Mint Pharmaceuticals Inc.
Formulary Listing Date
2020-01-31
Unit Price
1.4500
Amount MOH Pays
1.4500
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N03AX18
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02357658 | Vimpat | 5.8000 | 1.4500 |
| 02472937 | Teva-Lacosamide | 1.4500 | 1.4500 |
| 02474700 | Sandoz Lacosamide | 1.4500 | 1.4500 |
| 02478234 | Pharma-Lacosamide | 1.4500 | 1.4500 |
| 02499592 | NRA-Lacosamide | 1.4500 | 1.4500 |
| 02490579 | Mint-Lacosamide | 1.4500 | 1.4500 |
| 02487837 | Mar-Lacosamide | 1.4500 | 1.4500 |
| 02488426 | Jamp-Lacosamide | 1.4500 | 1.4500 |
| 02475367 | Auro-Lacosamide | 1.4500 | 1.4500 |
| 02489317 | Ach-Lacosamide | 1.4500 | 1.4500 |
| 02512904 | Lacosamide | 1.4500 | 1.4500 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 430 | Indefinite | As adjunctive therapy in the treatment of patients with partial onset seizures who have had an inadequate response or have significant intolerance to at least 3 less costly anticonvulsant therapies; AND Patients are under the care of a physician experienced in the treatment of epilepsy. Note: Less costly anticonvulsant therapies may include the following: |