Product Details

Pentoxifylline SR

Pentoxifylline
400 mg
SR Tablet


DIN/PIN/NPN

02230090

Manufacturer

A A Pharma Inc.

Formulary Listing Date

1997-08-28  

Unit Price

0.7238

Amount MOH Pays

0.7238

Coverage Status

Limited Use Product Chronic-Use Medication

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

C04AD03

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02221977 Trental NA NA
02230090 Pentoxifylline SR 0.7238 0.7238
02543087 Jamp Pentoxifylline SR 0.7238 0.7238
 

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
76 Indefinite

For the treatment of patients with critical limb ischemia (with arterial ulcers, gangrene and/or rest pain) and documented arterial vascular disease.

Note: Limited Use form must specify if arterial ulcers, gangrene and/or rest pain are present.

529 1 year

For the treatment of patients with venous ulcers lasting, or expected to last, more than 8 weeks. 

Treatment should be discontinued after 3 months if there is no indication of objective benefit. 

The duration of therapy with pentoxifylline should not exceed 12 months.

Note: Pentoxifylline should be used in combination with compression therapy.

 

EAP Criteria

NO

Product Monograph

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