Product Details

PMS-Iron Sucrose

Iron Sucrose
20 mg/mL
Solution for Injection
5-mL Pack (Preservative-Free)

DIN/PIN/NPN

02502917

Manufacturer

Pharmascience Inc.

Formulary Listing Date

2021-03-29  

Unit Price

27.5000

Amount MOH Pays

27.5000

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

B03AC

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02243716 Venofer NA NA
02502917 PMS-Iron Sucrose 27.5000 27.5000
 

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Anemia

Iron sucrose

  • Brand(s): Venofer, PMS Iron Sucrose
  • Dosage Form/Strength: 20 mg/mL Injectable

For the treatment of iron-deficiency anemia confirmed by bloodwork where the patient has a demonstrated intolerance1 to oral iron therapy2 OR has not responded to adequate therapy with oral iron2.

1Intolerance must be described.

2Provide name of iron salt, dose, duration of therapy, response, etc.

Duration of Approval: 1 year

Renewals will be considered on a case-by-case basis.

Duration of Approval: 2 years

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph