Product Details
Combigan
Brimonidine Tartrate + Timolol Maleate0.2% + 0.5%
Ophthalmic Solution
10-mL Pack
DIN/PIN/NPN
09857298
Manufacturer
Allergan Inc.
Formulary Listing Date
2008-08-28
Unit Price
46.5800
Amount MOH Pays
23.2900
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
S01ED51
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 09857298 | Combigan | 46.5800 | 23.2900 |
| 02375311 | Apo-Brimonidine-Timop | 23.2900 | 23.2900 |
| 02531704 | Jamp Brimonidine/Timolol | 23.2900 | 23.2900 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 310 | Indefinite | As second-line therapy for patients who do not have an adequate intraocular pressure lowering response to monotherapy with ophthalmic beta-blocking agents |
| 393 | Indefinite | For use as initial therapy in an urgent situation (e.g., patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective |