Product Details
PMS-Ipratropium
Ipratropium Bromide125 mcg/mL
Inhalation Solution
2-mL UDV Pack
DIN/PIN/NPN
02231135
Manufacturer
Pharmascience Inc.
Formulary Listing Date
1999-04-15
Unit Price
1.1505
Amount MOH Pays
1.1505
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 |
|---|---|---|---|
| 02231135 | PMS-Ipratropium | 1.1505 | 1.1505 |
| 02026759 | Atrovent UDV | NA | NA |
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. | ||
| 265 | Indefinite | Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have a tracheostomy; |
| 266 | Indefinite | Individuals must have a known hypersensitivity to the preservative in the bulk solution, and be patients with cystic fibrosis in whom nebulizer therapy is indicated; |
| 267 | Indefinite | Individuals must have a known hypersensitivity to the preservative in the bulk solution, and have severe mental or physical disabilities; |
| 268 | Indefinite | Patients who have previously used nebulizer therapy within the last 12-month period. |