Product Details
Med-Latanoprost
Latanoprost0.005%
Ophthalmic Solution
2.5-mL Pack
DIN/PIN/NPN
02426935
Manufacturer
Generic Medical Partners Inc.
Formulary Listing Date
2015-03-31
Unit Price
9.5830
Amount MOH Pays
9.5830
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01EE01
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02231493 | Xalatan | 34.1605 | 9.5830 |
| 02367335 | Sandoz Latanoprost | 9.5830 | 9.5830 |
| 02341085 | Riva-Latanoprost | 9.5830 | 9.5830 |
| 02426935 | Med-Latanoprost | 9.5830 | 9.5830 |
| 02489570 | Latanoprost Ophthalmic Solution | 9.5830 | 9.5830 |
| 02453355 | Jamp Latanoprost | 9.5830 | 9.5830 |
| 02373041 | Gd-Latanoprost | 9.5830 | 9.5830 |
| 02254786 | Co Latanoprost | 9.5830 | 9.5830 |
| 02296527 | Apo-Latanoprost | 9.5830 | 9.5830 |
| 02513285 | M-Latanoprost | 9.5830 | 9.5830 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 171 | Indefinite | As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated |
| 172 | Indefinite | As second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents |
| 387 | Indefinite | For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g., patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective |