Product Details

Ach-Donepezil

Donepezil HCl
5 mg
Tablet


DIN/PIN/NPN

02402645

Manufacturer

Accord Healthcare Inc.

Formulary Listing Date

2014-05-29  

Unit Price

0.4586

Amount MOH Pays

0.4586

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N06DA02

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02340607 Teva-Donepezil 0.4586 0.4586
02428482 Septa-Donepezil 0.4586 0.4586
02328666 Sandoz Donepezil 0.4586 0.4586
02381508 Ran-Donepezil 0.4586 0.4586
02322331 PMS-Donepezil 0.4586 0.4586
02439557 Nat-Donepezil 0.4586 0.4586
02408600 Mint-Donepezil 0.4586 0.4586
02467453 M-Donepezil 0.4586 0.4586
02402092 Mar-Donepezil 0.4586 0.4586
02416948 Jamp-Donepezil Tablets 0.4586 0.4586
02404419 Jamp-Donepezil 0.4586 0.4586
02402645 Ach-Donepezil 0.4586 0.4586
02475278 Donepezil 0.4586 0.4586
02426846 Donepezil 0.4586 0.4586
02397595 Co Donepezil 0.4586 0.4586
02412853 Bio-Donepezil 0.4586 0.4586
02400561 Auro-Donepezil 0.4586 0.4586
02232043 Aricept 5.1856 0.4586
02362260 Apo-Donepezil 0.4586 0.4586
02432684 AG-Donepezil 0.4586 0.4586
02420597 Donepezil 0.4586 0.4586
02535386 NRA-Donepezil 0.4586 0.4586
 

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
347 1 year

Initial Trial: For patients with mild to moderate Alzheimer's Disease (Mini-Mental State Exam [MMSE] 10-26). Patients will be reimbursed for a period of up to 3 months after which continued treatment must be reassessed.

Network note: Maximum duration 3 months.

348 1 year

Continuation: Further reimbursement will be made available to those patients whose disease has not progressed/deteriorated while on this drug. Patients must continue to have a MMSE score of 10-26.

 

EAP Criteria

NO

Product Monograph

View Monograph