Product Details

Rapamune

Sirolimus
1 mg
Tablet


DIN/PIN/NPN

02247111

Manufacturer

Wyeth Pharmaceuticals

Formulary Listing Date

2005-02-22  

Unit Price

9.6855

Amount MOH Pays

9.6855

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

L04AA10

Interchangeable Products

NO  

LU 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

  • Brand(s): Rapamune
  • Dosage Form/Strength: 1 mg tablet, 1 mg/mL oral liquid

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.

Product Monograph

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