Product Details
Lomotil
Diphenoxylate Hydrochloride + Atropine Sulfate2.5 mg + 0.025 mg
Tablet
DIN/PIN/NPN
00036323
Manufacturer
Pfizer Canada Inc.
Formulary Listing Date
1996-10-01
Unit Price
0.5583
Amount MOH Pays
0.5583
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
A07DA01
Interchangeable Products
NOLU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| Note: For the treatment of diarrhea associated with: | ||
| 110 | 1 year | An ileostomy or a colostomy; |
| 111 | 1 year | Bowel resection, including short bowel syndrome; |
| 112 | 1 year | Inflammatory Bowel Diseases, i.e. Crohn's Disease and Ulcerative Colitis; |
| 113 | 1 year | Cancer, including chemotherapy or radiation therapy; |
| 114 | 1 year | HIV/AIDS; |
| 115 | 1 year | Acute diarrhea in patients in congregated housing, i.e. Long Term Care Facilities (LTCF), or for patients receiving Home Care; |
| 224 | 1 year | Fecal incontinence. |