Product Details
Rapamune
Sirolimus1 mg/mL
Oral Liquid
DIN/PIN/NPN
02243237
Manufacturer
Wyeth Pharmaceuticals
Formulary Listing Date
2005-02-22
Unit Price
9.4400
Amount MOH Pays
9.4400
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
L04AA10
Interchangeable Products
NOLU Clinical Criteria
LU Code | Auth. Period | Clinical Criteria |
---|---|---|
392 | Indefinite | For the prophylaxis of organ rejection in patients receiving allogeneic renal transplants. |
EAP Criteria
Therapeutic Class | Reimbursement Criteria |
---|---|
Post-transplant Drugs – Telephone Request Service (TRS) Drugs | Sirolimus
For liver transplant recipients who require regimens that mandate calcineurin inhibitor avoidance. The physician must be able to explain clearly why the patient cannot use a calcineurin inhibitor. NOTE: Rapamune is currently listed on the ODB Formulary as a Limited Use (LU) benefit for the prophylaxis of organ rejection in patients receiving allogeneic renal transplants. |