Product Details
Lumigan RC
Bimatoprost0.01%
Ophthalmic Solution
5-mL Pack
DIN/PIN/NPN
09857368
Manufacturer
Allergan Inc.
Formulary Listing Date
2010-09-09
Unit Price
60.1892
Amount MOH Pays
30.0945
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 09857368 | Lumigan RC | 60.1892 | 30.0945 |
| 02529580 | Bimatoprost RC | 30.0945 | 30.0945 |
| 02565773 | Jamp Bimatoprost Solution RC | 30.0945 | 30.0945 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 171 | Indefinite | As first line treatment of elevated intraocular pressure in patients who cannot tolerate an ophthalmic beta-blocking agent or where beta-blocking agents are contraindicated |
| 172 | Indefinite | As second line monotherapy or combination therapy in patients who do not have an adequate intraocular pressure lowering response to ophthalmic beta-blocking agents |
| 387 | Indefinite | For use as adjunctive therapy with an ophthalmic beta-blocking agent in an urgent situation (e.g., patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective |
Requirements