Product Details

Dostinex

Cabergoline
0.5 mg
Tablet

DIN/PIN/NPN

02242471

Manufacturer

Pharmacia & Upjohn

Formulary Listing Date

2008-06-27

Unit Price

22.3875

Amount MOH Pays

12.3941

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

92:00:00 Unclassified Therapeutic Agents

Therapeutic Note

NO

ATC Code

G02CB03

Interchangeable Products

DIN/ PIN/ NPN	Brand name	Unit Price	Amount MOH pays
02242471	Dostinex	22.3875	12.3941
02455897	Apo-Cabergoline	12.3941	12.3941

LU Clinical Criteria

LU Code	Auth. Period	Clinical Criteria
656	Indefinite	For the treatment of hyperprolactinemia.

EAP Criteria

Therapeutic Class	Reimbursement Criteria
Endocrinology Agents	Cabergoline Brand(s): Dostinex and generics (see formulary for OFI listings) Dosage Form/Strength: 0.5 mg tablets For the treatment of hyperprolactinemia. Note that cabergoline may be used as any line of therapy for hyperprolactinemia (i.e., first or subsequent lines) Approval duration: Lifetime EAP Drug Request Form: Standard Form for EAP Drug Requests

Product Monograph