Product Details

Xenical

Orlistat
120 mg
Capsule


DIN/PIN/NPN

02240325

Manufacturer

Xediton Pharmaceuticals Inc.

Formulary Listing Date

2016-04-29  

Unit Price

1.6574

Amount MOH Pays

1.6574

Coverage Status

Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

A08AB01

Interchangeable Products

NO  

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Antidiabetic Agents

Orlistat

  • Brand(s): Xenical
  • Dosage Form/Strength: 120 mg capsule

For the treatment of type 2 diabetes in a patient with:

  1. Inadequate glycemic control (i.e., HbA1c > 7.0%) on maximal oral antidiabetic medications* AND 

  2. Body Mass Index ≥ 27 AND 

  3. Demonstrated failure to a trial of nutritional/dietary counselling and exercise programs

*Note: Maximal dose of sulfonylurea is considered to be glyburide 10mg/day, gliclazide 160mg/day (or Diamicron MR 60 mg/day), OR glimepiride (Amaryl) 4mg/day.
Maximal dose of metformin is considered to be 2000 mg/day

Duration of Approval: 1 year 

Renewals will be considered for those with demonstrated response to treatment reported as at least 5% weight loss and improvement in glycemic control (i.e., HbA1c less than 7.0% or HbA1c reduction of more than 0.5%)

Duration of Approval: 12 months (First Renewal)

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

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