Product Details
PMS-Tenofovir
Tenofovir Disoproxil300 mg
Tablet
DIN/PIN/NPN
02453940
Manufacturer
Pharmascience Inc.
Formulary Listing Date
2018-06-29
Unit Price
4.8884
Amount MOH Pays
4.8884
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
J05AF07
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02247128 | Viread | 19.5537 | 4.8884 |
| 02403889 | Teva-Tenofovir | 4.8884 | 4.8884 |
| 02512327 | Tenofovir | 4.8884 | 4.8884 |
| 02453940 | PMS-Tenofovir | 4.8884 | 4.8884 |
| 02472511 | Nat-Tenofovir | 4.8884 | 4.8884 |
| 02452634 | Mylan-Tenofovir Disoproxil | 4.8884 | 4.8884 |
| 02479087 | Jamp-Tenofovir | 4.8884 | 4.8884 |
| 02460173 | Auro-Tenofovir | 4.8884 | 4.8884 |
| 02451980 | Apo-Tenofovir | 4.8884 | 4.8884 |
| 02512939 | Mint-Tenofovir | 4.8884 | 4.8884 |
| 02523922 | Tenofovir | 4.8884 | 4.8884 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 517 | 1 year | Confirmed chronic Hepatitis B infection in persons with - HBV DNA greater than or equal to 1000 IU/mL AND - ALT levels greater than ULN OR - Evidence of fibrosis OR - Documented evidence of cirrhosis |
| 518 | 1 year | For patients with chronic Hepatitis B infection who have a contraindication, intolerance or inadequate response to one or more of the following: lamivudine, entecavir, adefovir or telbivudine. |
| 519 | 1 year | Patient is pregnant (2nd trimester or later) with HBV DNA greater than 1,000,000 IU/mL. |
| 520 | 1 year | Patients with chronic Hepatitis B infection currently receiving treatment with tenofovir and requires treatment continuation. |
| 521 | 1 year | Patients with chronic Hepatitis B infection who are scheduled to undergo chemotherapy or significant immunosuppressive treatment. |
| 522 | 1 year | For HIV/AIDS. |