Product Details
Tetrabenazine Tablets
Tetrabenazine25 mg
Tablet
DIN/PIN/NPN
02410338
Manufacturer
SteriMax Inc.
Formulary Listing Date
2014-01-03
Unit Price
4.8551
Amount MOH Pays
4.8551
Coverage Status
Off-Formulary Interchangeable Exceptional Access Program Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N07XX06
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
02410338 | Tetrabenazine Tablets | 4.8551 | 4.8551 |
02402424 | PMS-Tetrabenazine | 4.8551 | 4.8551 |
02199270 | Nitoman | NA | NA |
02407590 | Apo-Tetrabenazine | 4.8551 | 4.8551 |
LU Clinical Criteria
NOEAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Central Nervous System Drugs | Tetrabenazine
For the treatment of Hungtington’s chorea, tic and Gille’s de la Toureet syndrome and tardive dyskinesia in patients meeting the following criteria:
**Note that for patients with disabling tardive dyskinesia, a trial of a Formulary agent is NOT required (i.e., tetrabenazine can be considered for use as a first-line agent) Duration of Approval: 1 year Renewals will be considered for patients whose request is prescribed by (or in consultation with) physicians who are experienced in the treatment of hyperkinetic movement disorders (e.g., specialists practicing in a Movement Disorder Clinic, neurologists, psychiatrists, physiatrists, geriatricians, pediatricians); AND who provide written confirmation that movements and functional status are stabilized on tetrabenazine therapy. Duration of Approval: 5 years For the treatment of Hemiballismus, senile chorea, or other disabling hyperkinetic movement disorders (HKMD) will be considered on a case-by-case basis in patients meeting the following criteria:
Duration of Approval: 1 year Renewals will be considered for patients whose request is prescribed by (or in consultation with) physicians who are experienced in the treatment of hyperkinetic movement disorders (e.g., specialists practicing in a Movement Disorder Clinic, neurologists, psychiatrists, physiatrists, geriatricians, pediatricians); AND who provide written confirmation that movements and functional status are stabilized on tetrabenazine therapy. Duration of Approval: 5 years Please note that information MUST BE provided about why a patient has not tried or cannot try a formulary alternative. Requests not meeting the above criteria for HKMD will be considered through a case-by-case review and the physician must provide adequate clinical information to enable this assessment. EAP Drug Request Form: |