Product Details
Pentoxifylline SR
Pentoxifylline400 mg
SR Tablet
DIN/PIN/NPN
02230090
Manufacturer
A A Pharma Inc.
Formulary Listing Date
1997-08-28
Unit Price
0.8042
Amount MOH Pays
0.8042
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 | 0.8042 | 0.8042 |
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. |