AMBRISENTAN
ambrisentan 5 mg tablet, 30
AMBRISENTAN (12201E)
12201E
Body System:
Manner of administration:Oral
Restriction
Indication: Pulmonary arterial hypertension (PAH)
Treatment phase: Initial 1 - combination therapy (dual or triple therapy, excluding selexipag) in an
untreated patient
Restriction
Indication: Pulmonary arterial hypertension (PAH)
Treatment phase: Initial 2 - starting combination therapy (dual or triple therapy, excluding selexipag)
in a treated patient where a diagnosis of pulmonary arterial hypertension is established
through a prior PBS authority application
Restriction
Indication: Pulmonary arterial hypertension (PAH)
Treatment phase: Initial 3 - changing to this drug in combination therapy (dual or triple therapy)
Restriction
Indication: Pulmonary arterial hypertension (PAH)
Treatment phase: Continuing treatment of combination therapy (dual or triple therapy, excluding selexipag)
Restriction
Indication: Pulmonary arterial hypertension (PAH)
Treatment phase: Triple therapy - Initial treatment or continuing treatment of triple combination therapy
(including dual therapy in lieu of triple therapy) that includes selexipag
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 30 | # of repeats: 5 | DPMQ: $1,268.63 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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