M-Donepezil

Donepezil HCl
10 mg
Tablet

DIN/PIN/NPN

02467461

Mantra Pharma Inc.

2021-10-29

0.4586

0.4586

Limited Use Product

N06DA02

DIN/ PIN/ NPN	Brand name	Unit Price	Amount MOH pays
02340615	Teva-Donepezil	0.4586	0.4586
02428490	Septa-Donepezil	0.4586	0.4586
02328682	Sandoz Donepezil	0.4586	0.4586
02381516	Ran-Donepezil	0.4586	0.4586
02322358	PMS-Donepezil	0.4586	0.4586
02439565	Nat-Donepezil	0.4586	0.4586
02408619	Mint-Donepezil	0.4586	0.4586
02467461	M-Donepezil	0.4586	0.4586
02402106	Mar-Donepezil	0.4586	0.4586
02416956	Jamp-Donepezil Tablets	0.4586	0.4586
02404427	Jamp-Donepezil	0.4586	0.4586
02402653	Ach-Donepezil	0.4586	0.4586
02475286	Donepezil	0.4586	0.4586
02426854	Donepezil	0.4586	0.4586
02397609	Co Donepezil	0.4586	0.4586
02412861	Bio-Donepezil	0.4586	0.4586
02400588	Auro-Donepezil	0.4586	0.4586
02232044	Aricept	5.1856	0.4586
02362279	Apo-Donepezil	0.4586	0.4586
02432692	AG-Donepezil	0.4586	0.4586
02420600	Donepezil	0.4586	0.4586
02535394	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.