Product Details

Revia

Naltrexone HCl
50 mg
Tablet


DIN/PIN/NPN

02213826

Manufacturer

Teva Canada Limited

Formulary Listing Date

2015-11-26  

Unit Price

2.8075

Amount MOH Pays

2.8075

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N07BB04

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02213826 Revia 2.8075 2.8075
02451883 Naltrexone Hydrochloride Tablets USP 2.8075 2.8075
02444275 Apo-Naltrexone 2.8075 2.8075
 

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
532 1 year

For the treatment of alcohol use disorder in patients who:

- Meet clinical criteria for alcohol use disorder; and

- Express a commitment to reduce or abstain from alcohol; and

- Have confirmed participation in counselling and treatment for alcohol use disorder*


* An individualized treatment plan will have one or more of the following components: Counselling and follow-up with the patient's family physician, addiction physician, or psychiatrist; self-help groups such as Alcoholics Anonymous; and outpatient, day, or inpatient psychosocial rehabilitation programs.

 

EAP Criteria

NO

Product Monograph

View Monograph