Product Details

Mylan-Riluzole

Riluzole
50 mg
Tablet


DIN/PIN/NPN

02390299

Manufacturer

Mylan Pharmaceuticals ULC

Formulary Listing Date

2012-12-21  

Unit Price

7.3630

Amount MOH Pays

7.3630

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N07XX02

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02242763 Rilutek 10.5500 7.3630
02390299 Mylan-Riluzole 7.3630 7.3630
02352583 Apo-Riluzole 7.3630 7.3630
 

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Central Nervous System Drugs

Riluzole

  • Brand(s): Rilutek
  • Dosage Form/Strength: 50 mg tablet

Approvals will be provided for: 

Patients who have probable or definite amyotrophic lateral sclerosis (ALS) as defined by World Federation of Neurology (WFN) criteria with onset within 5 years, who have a vital capacity of >60% predicted and do not have a tracheostomy. 

Discontinuation Criteria: 

Reimbursement will be discontinued if the patient progresses to require permanent assisted ventilation. This is defined as assisted ventilation required for 23 out of 24 hours for greater than or equal to 14 consecutive days.

Renewal Criteria:

Renewals will be considered in patients who do not meet the discontinuation criteria. 

Approval period of initials and renewals: 12 months

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph