Product Details
Sandoz Travoprost
Travoprost0.004%
Ophthalmic Solution
5-mL Pack
DIN/PIN/NPN
02413167
Manufacturer
Sandoz Canada Inc.
Formulary Listing Date
2014-10-29
Unit Price
43.1400
Amount MOH Pays
43.1400
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01EE04
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
09857332 | Travatan Z | 58.9600 | 43.1400 |
02413167 | Sandoz Travoprost | 43.1400 | 43.1400 |
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 |