Product Details
Apo-Fingolimod
Fingolimod0.5 mg
Capsule
DIN/PIN/NPN
02469936
Manufacturer
Apotex Inc.
Formulary Listing Date
2019-12-20
Unit Price
73.9096
Amount MOH Pays
73.9096
Coverage Status
Off-Formulary Interchangeable Exceptional Access Program Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
L04AA27
Interchangeable Products
DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
---|---|---|---|
02469561 | Teva-Fingolimod | 73.9096 | 73.9096 |
02469618 | Taro-Fingolimod | 73.9096 | 73.9096 |
02482606 | Sandoz Fingolimod | 73.9096 | 73.9096 |
02469782 | PMS-Fingolimod | 73.9096 | 73.9096 |
02469715 | Mylan-Fingolimod | 73.9096 | 73.9096 |
02474743 | Mar-Fingolimod | 73.9096 | 73.9096 |
02487772 | Jamp Fingolimod | 73.9096 | 73.9096 |
02365480 | Gilenya | 86.9525 | 73.9100 |
02469936 | Apo-Fingolimod | 73.9096 | 73.9096 |
02475669 | ACH-Fingolimod | 73.9100 | 73.9100 |
LU Clinical Criteria
NOEAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Multiple Sclerosis Drugs | Fingolimod
As monotherapy for the treatment of patients with Relapsing Remitting Multiple Sclerosis (RRMS) who meet all of the following criteria:
Exclusion Criteria (Patients meeting any of the following exclusion criteria will not be funded):
Dosage: 0.5 mg once daily 1Failure to respond to full and adequate courses: defined as having received a trial of at least 6 months of interferon or glatiramer or dimethyl fumarate therapy or teriflunomide AND experienced at least one disabling relapse (attack) while on interferon or glatiramer or dimethyl fumarate or teriflunomide. MRI reports do NOT need to be submitted with the initial request. Duration of Approval: 1 year Renewals are considered. Renewals can be submitted through the Telephone Request Service and will be considered for patients who have benefited from therapy. Physicians must provide the following information:
Dosage: 0.5 mg once daily. Duration of Approval: EAP Drug Request Form: |
Renewals of Multiple Sclerosis Drugs – Telephone Request Service (TRS) Drugs | Fingolimod
EAP will renew coverage of Fingolimod for patients with RRMS who are stable and experienced no more than one disabling attack/relapse in the past year and have an EDSS score less than or equal to 5.5. Prescriber must provide the following information:
Standard Approval Duration: 2 years for first renewal; 5 years for 2nd and subsequent renewals. Renewal requests where patients have experienced more than 1 attack in the past year will be externally reviewed. |