Product Details
Apo-Riluzole
Riluzole50 mg
Tablet
DIN/PIN/NPN
02352583
Manufacturer
Apotex Inc.
Formulary Listing Date
2012-11-27
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
NOEAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Central Nervous System Drugs | Riluzole
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: |