Product Details
Act Levetiracetam
Levetiracetam500 mg
Tablet
DIN/PIN/NPN
02274191
Manufacturer
Actavis Pharma Company
Formulary Listing Date
2007-12-19
Unit Price
0.3911
Amount MOH Pays
0.3911
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
N03AX14
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02461994 | Sandoz Levetiracetam | 0.3911 | 0.3911 |
| 02482282 | Riva-Levetiracetam | 0.3911 | 0.3911 |
| 02499207 | NRA-Levetiracetam | 0.3911 | 0.3911 |
| 02440210 | Nat-Levetiracetam | 0.3911 | 0.3911 |
| 02399784 | Ach-Levetiracetam | 0.3911 | 0.3911 |
| 02454661 | Levetiracetam | 0.3911 | 0.3911 |
| 02442558 | Levetiracetam | 0.3911 | 0.3911 |
| 02353350 | Levetiracetam | 0.3911 | 0.3911 |
| 02247028 | Keppra | 2.1725 | 0.3911 |
| 02403021 | Jamp-Levetiracetam | 0.3911 | 0.3911 |
| 02375257 | Auro-Levetiracetam | 0.3911 | 0.3911 |
| 02285932 | Apo-Levetiracetam | 0.3911 | 0.3911 |
| 02274191 | Act Levetiracetam | 0.3911 | 0.3911 |
| 02504561 | Jamp Levetiracetam Tablets | 0.3911 | 0.3911 |
| 02524570 | M-Levetiracetam | 0.3911 | 0.3911 |
| 02442396 | Mint-Levetiracetam | 0.3911 | 0.3911 |
| 02296128 | PMS-Levetiracetam | 0.3911 | 0.3911 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 473 | Indefinite | As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. |