Product Details
Hanzema
Alitretinoin30 mg
Capsule
DIN/PIN/NPN
02477440
Manufacturer
Dr. Reddy's Laboratories Inc.
Formulary Listing Date
2021-07-30
Unit Price
16.9868
Amount MOH Pays
16.9868
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
Alitretinoin: Alitretinoin should only be prescribed by physicians knowledgeable in the use of retinoids systemically, who understand the risk of teratogenicity in females of childbearing potential. Alitretinoin is contraindicated in pregnancy and females must not become pregnant while taking alitretinoin and for at least one month after its discontinuation. Please refer to the Hanzema product monograph for details on use in women of childbearing potential.
ATC Code
D11AH04
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02337649 | Toctino | NA | NA |
| 02477440 | Hanzema | 16.9868 | 16.9868 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 442 | 1 year | For adult patients with severe (see note 1 below) chronic (see note 2 below) hand eczema AND unresponsive to an 8-week course of high potency topical corticosteroids. Notes: 1. Severe defined based on the Physician Global Assessment (PGA), including: - At least one of the following cardinal features present at baseline as moderate or severe: erythema, scaling, hyperkeratosis/lichenification; and - with an area of greater than 30% of affected hand surface 2. Chronic defined as: - persists for greater than 3 months; OR - reoccurs greater than or equal to 2 times within 12 months |