Product Details
PMS-Loperamide
Loperamide HCl2 mg
Caplet
DIN/PIN/NPN
02228351
Manufacturer
Pharmascience Inc.
Formulary Listing Date
1998-12-31
Unit Price
0.0952
Amount MOH Pays
0.0952
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
A07DA03
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02132591 | Teva-Loperamide | 0.0952 | 0.0952 |
| 02228351 | PMS-Loperamide | 0.0952 | 0.0952 |
| 00860743 | Imodium | NA | NA |
| 02212005 | Apo-Loperamide | 0.0952 | 0.0952 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| Note: For the treatment of diarrhea associated with: | ||
| 110 | 1 year | An ileostomy or a colostomy; |
| 111 | 1 year | Bowel resection, including short bowel syndrome; |
| 112 | 1 year | Inflammatory Bowel Diseases, i.e. Crohn's Disease and Ulcerative Colitis; |
| 113 | 1 year | Cancer, including chemotherapy or radiation therapy; |
| 114 | 1 year | HIV/AIDS; |
| 115 | 1 year | Acute diarrhea in patients in congregated housing, i.e. Long Term Care Facilities (LTCF), or for patients receiving Home Care; |
| 224 | 1 year | Fecal incontinence. |