Product Details
Jamp-Vancomycin
Vancomycin HCl125 mg
Capsule
DIN/PIN/NPN
02407744
Manufacturer
Jamp Pharma Corporation
Formulary Listing Date
2016-12-22
Unit Price
5.1800
Amount MOH Pays
5.1800
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
A07AA09
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
00800430 | Vancocin | 5.1800 | 5.1800 |
02407744 | Jamp-Vancomycin | 5.1800 | 5.1800 |
LU Clinical Criteria
LU Code | Auth. Period | Clinical Criteria |
---|---|---|
557 | 14 days | For the treatment of initial episodes of Clostridium difficile infection; mild cases, if no response or intolerance to an adequate trial of oral metronidazole*: *As defined by the Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection, 2018. Notes: Maximum funded dose: Vancomycin 125mg four times daily, up to 14 days Maximum funded quantity: 56 capsules |
558 | 14 days | For the treatment of initial episodes of Clostridium difficile infection; moderate or severe, uncomplicated cases*: *As defined by the Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection, 2018. Notes: Maximum funded dose: Vancomycin 125mg four times daily, up to 14 days Maximum funded quantity: 56 capsules |
559 | 14 days | For the treatment of recurrent Clostridium difficile infection (CDI), first recurrence, mild to moderate* or severe, uncomplicated* cases: *As defined by the Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection, 2018. Notes: Maximum funded dose: Vancomycin 125mg four times daily, up to 14 days Maximum funded quantity: 56 capsules |
560 | 13 weeks | For the treatment of recurrent Clostridium difficile infection (CDI), second or subsequent recurrences, mild to moderate* or severe, uncomplicated* cases: *As defined by the Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection, 2018. Notes: Funded dose: Vancomycin 125mg four times daily for 10-14 days, followed by vancomycin taper. Maximum funded quantity: 114 capsules |
EAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Anti-Infectives | Vancomycin
Effective September 30, 2019, Vancomycin oral tablets for the treatment of Uncomplicated Clostridium difficile infection may be accessed upon meeting Limited Use Criteria on the Ontario Drug Benefit Formulary. Vancomycin Injection to be used as an oral solution for Clostridium difficile Infection may be accessed through the Telephone Request Service. Case-by-case consideration for requests not meeting the Limited Use criteria (e.g., higher doses, longer durations, tapering regimens exceeding the dosing limits under LU, complicated C. difficile Infections) may be considered through external review. Please submit requests to EAP providing adequate and relevant clinical details to support the request. EAP Drug Request Form: |