Product Details

Jamp Dienogest

Dienogest
2 mg
Tablet


DIN/PIN/NPN

02498189

Manufacturer

Jamp Pharma Corporation

Formulary Listing Date

2021-02-26  

Unit Price

0.5115

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.

 

EAP Criteria

NO

Product Monograph

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