Product Details
Visanne
Dienogest2 mg
Tablet
DIN/PIN/NPN
02374900
Manufacturer
Bayer Inc., Health Care Division
Formulary Listing Date
2012-07-27
Unit Price
2.1876
Amount MOH Pays
0.5115
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
G03DB08
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02374900 | Visanne | 2.1876 | 0.5115 |
| 02498189 | Jamp Dienogest | 0.5115 | 0.5115 |
| 02493055 | Aspen-Dienogest | 0.5115 | 0.5115 |
| 02543613 | M-Dienogest | 0.5115 | 0.5115 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 432 | 1 year | For the management of pelvic pain associated with endometriosis in patients for whom one or more less costly options are either ineffective or cannot be used. Note: For example, for patients who are refractory to 6 months of continuous combined oral contraceptives and/or medroxyprogesterone therapy OR have contraindications to these therapies. |