Product Details

Fycompa

Perampanel
2 mg
Tablet


DIN/PIN/NPN

02404516

Manufacturer

Eisai Limited

Formulary Listing Date

2014-02-27  

Unit Price

10.3869

Amount MOH Pays

5.7128

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N03AX22

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02404516 Fycompa 10.3869 5.7128
02522632 Taro-Perampanel 5.7128 5.7128
 

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:
 
Phenytoin, Carbamazepine, Gabapentin, Lamotrigine, Vigabatrin, Topiramate, etc.

564 Indefinite

For adjunctive therapy in the management of primary generalized tonic-clonic (PGTC) seizures in patients with epilepsy 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:

Phenytoin, Carbamazepine, Gabapentin, Lamotrigine, Vigabatrin, Topiramate, etc.

 

EAP Criteria

NO

Product Monograph

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