Co Donepezil

Donepezil HCl
5 mg
Tablet

DIN/PIN/NPN

02397595

Cobalt Pharmaceuticals Company

2014-02-27

0.4586

0.4586

Limited Use Product

N06DA02

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 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.