Product Details

Mar-Midodrine

Midodrine HCl
5 mg
Tablet


DIN/PIN/NPN

02473992

Manufacturer

Marcan Pharmaceuticals Inc.

Formulary Listing Date

2018-11-29  

Unit Price

0.1921

Amount MOH Pays

0.1921

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

C01CA17

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02473992 Mar-Midodrine 0.1921 0.1921
02278685 Apo-Midodrine 0.1921 0.1921
01934406 Amatine NA NA
02517728 Jamp Midodrine 0.1921 0.1921
02533219 Midodrine 0.1921 0.1921
 

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
1 Indefinite

For the treatment of patients disabled by moderate to severe neurogenic orthostatic hypotension (i.e., drop in systolic BP less than or equal to 20mm Hg from supine to standing position), in whom conventional nonpharmacologic and pharmacologic (i.e., fludrocortisone) therapies have proven ineffective or are poorly tolerated.

 

EAP Criteria

NO

Product Monograph

View Monograph