Product Details

Hanzema

Alitretinoin
10 mg
Capsule


DIN/PIN/NPN

02477432

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
02337630 Toctino NA NA
02477432 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
    
-  one of the following features present as severe: vesiculation, edema, fissures, pruritus/pain; 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

 

EAP Criteria

NO

Product Monograph

View Monograph