Product Details

Dostinex

Cabergoline
0.5 mg
Tablet

DIN/PIN/NPN

02242471

Manufacturer

Pharmacia & Upjohn

Formulary Listing Date

2008-06-27

Unit Price

23.0588

Amount MOH Pays

7.2907

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	23.0588	7.2907
02455897	Apo-Cabergoline	7.2907	7.2907
02549611	Jamp Cabergoline	7.2907	7.2907

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