Product Details
Dysport Therapeutic
Abobotulinum Toxin A500 U/Vial
Powder for Injection
Vial
DIN/PIN/NPN
02456117
Manufacturer
Ipsen Limited
Formulary Listing Date
2018-09-27
Unit Price
642.6000
Amount MOH Pays
642.6000
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
M03AX01
Interchangeable Products
NOLU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| Note: Dysport Therapeutic should be administered personally by a neurologist, pediatrician, or a physician with equivalent post-graduate training and experience with neuromuscular disorders. | ||
| 130 | 1 year | To reduce the subjective symptoms and objective signs of cervical dystonia (spasmodic torticollis) in adults |
| 412 | 1 year | For the management of focal spasticity, due to stroke or spinal cord injury in adults |
| 413 | 1 year | For the treatment of focal spasticity secondary to cerebral palsy in patients two years of age or older |