Product Details
PMS-Ipratropium
Ipratropium Bromide250 mcg/mL
Inhalation Solution
20-mL Pack
DIN/PIN/NPN
02231136
Manufacturer
Pharmascience Inc.
Formulary Listing Date
1999-04-15
Unit Price
6.3140
Amount MOH Pays
6.3140
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
- 12:08:00 Parasympatholytic (Cholinergic Blocking) Agents
- 52:36:00 Other Eye, Ear, Nose and Throat Agents
Therapeutic Note
NO
ATC Code
R03BB01
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02231136 | PMS-Ipratropium | 6.3140 | 6.3140 |
| 02210479 | Novo-Ipramide | 6.3140 | 6.3140 |
| 00731439 | Atrovent | NA | NA |
| 02126222 | AA-Ipravent | 6.3140 | 6.3140 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| Note: For the vast majority of patients, a metered dose inhaler is the preferred therapy. Nebulizer therapy will be reimbursed for patients who are unable to use a metered dose inhaler, including an inhaler with a spacer attachment, or a turbuhaler. | ||
| 256 | Indefinite | Patients who have a tracheostomy; |
| 257 | Indefinite | Patients with cystic fibrosis in whom nebulizer therapy is indicated; |
| 258 | Indefinite | Patients with severe mental or physical disabilities; |
| 259 | Indefinite | Patients who have previously used nebulizer therapy within the last 12-month period. |