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Reason for Use code 473 As adjunctive therapy in the treatment of seizure disorders where control by other listed anticonvulsants has been unsatisfactory. Coverage limit: LU Authorization Period: Indefinite

Lowest DBP recovery rule under medically necessary no-substitution claims: 6.2 Medically Necessary "No Substitution" Claims The Side Effect Reporting Form will not have to be renewed. However, the pharmacy must maintain a copy of the prescription that contains a direction that there be no substitution and the required Health Canada Side Effect Reporting Form (completed and signed by the prescriber). The prescriber must write “No Substitution” or “No Sub” on renewal or subsequent new written prescriptions, and indicate “No Substitution” on subsequent new oral prescriptions. The dispenser will be reimbursed the DBP plus a mark-up and the lesser of the posted usual and customary fee or the ODB dispensing fee minus the applicable ODB co-payment amount. Where a completed Side Effect Reporting Form is not available at the pharmacy during an inspection, the difference between the cost of the higher-cost product and the lowest DBP listed for the interchangeable category will be recovered. (ontario.ca, Revision #17; 2026-08-03 ↗) 6.2 Medically Necessary "No Substitution" Claims The Ministry will provide reimbursement of a higher-cost interchangeable product in medically necessary circumstances where a patient has experienced a significant adverse reaction with two (2) lower-cost interchangeable drug products, where available. When a prescriber identifies a patient for which it is medically necessary that a higher cost interchangeable product be provided, the prescriber must: • Complete, sign and forward to the pharmacist a copy of the Health Canada side effect reporting form for each lower-cost interchangeable drug product trialed (Side Effect Reporting Form[s]); and • Write “No Substitution” or “No Sub” on a written prescription or indicate “No Substitution” to the pharmacist in the case of a verbal prescription. The prescriber should keep a copy of the completed form in the patient’s record for future use and reference. In the case of a written prescription, when the pharmacist or dispensing physician receives a prescription with the written notation “No Substitution” or “No Sub”, reimbursement will be provided for the higher-cost interchangeable product only if the prescription is accompanied by a completed Health Canada Side Effect Reporting Form for each of the lower-cost interchangeable drug products trialed. This form must be completely filled out noting the details of the adverse reaction and signed by the prescriber. In the case of a verbal prescription, the prescriber must satisfy the operator of the pharmacy or dispensing physician that a completed Health Canada Side Effect Reporting Form for each of the lower-cost interchangeable drug products trialed has been completed and signed by the prescriber. A written record of this verbal prescription and the completed Health Canada Side Effect Reporting Form must be received by the pharmacy prior to claim submission. Upon receipt, the pharmacist must: • Fax, submit online or mail the completed and signed form to Health Canada’s Canada Vigilance Program; and • Retain his or her copy of the completed and signed Side Effect Reporting Form. (ontario.ca, Revision #17; 2026-08-03 ↗)

Levetiracetam · DIN 02442558 Manufacturer: Sivem Pharmaceuticals ULC; listing date 2020-08-28 Health Canada: Marketed since 2018-04-13 · brand LEVETIRACETAM · ATC N03AX14 LEVETIRACETAM · form Tablet · route Oral · ingredients LEVETIRACETAM 500 MG · company Sivem pharmaceuticals ulc · schedule Prescription

DIN 02442558: Levetiracetam Raw flags: sec12=Y, sec3=Y Item: 281200092; group id 434; item number 1084; lccId 00266; manufacturer id SIV Source form: Tab; strength: 500mg Recorded listing: Limited Use: paid only with a Reason for Use code and the criteria below Source prices (unrounded): $0.3911; ministry $0.3911 Source: ODB odb-formulary-ed43-extract-2026-08-26.xml extract_date=2026-08-26 DIN=02442558 Health Canada DPD extract of Sep 2, 2026 (Open Government Licence – Canada) · https://health-products.canada.ca/dpd-bdpp/info?lang=eng&code=92689

Interchangeable products

Ach-Levetiracetam · DIN 02399784 · $0.3911 Act Levetiracetam · DIN 02274191 · $0.3911 Apo-Levetiracetam · DIN 02285932 · $0.3911 Auro-Levetiracetam · DIN 02375257 · $0.3911 Jamp Levetiracetam Tablets · DIN 02504561 · $0.3911 Jamp-Levetiracetam · DIN 02403021 · $0.3911 Keppra · DIN 02247028 · $0.3911 Levetiracetam · DIN 02353350 · $0.3911 M-Levetiracetam · DIN 02524570 · $0.3911 Mint-Levetiracetam · DIN 02442396 · $0.3911 NRA-Levetiracetam · DIN 02499207 · $0.3911 PMS-Levetiracetam · DIN 02296128 · $0.3911 Riva-Levetiracetam · DIN 02482282 · $0.3911 Sandoz Levetiracetam · DIN 02461994 · $0.3911

Shortage status: not checked (no credentials)