Source	S100 HSD Private
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14107LMP	ELTROMBOPAG eltrombopag 50 mg tablet, 28 (PI, CMI)	3	84	3	$7,417.59	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Public
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14112RMP	ELTROMBOPAG eltrombopag 50 mg tablet, 28 (PI, CMI)	3	84	5	$7,368.72	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Private
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14115XMP	ELTROMBOPAG eltrombopag 25 mg tablet, 28 (PI, CMI)	3	84	3	$3,733.23	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Private
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14119DMP	ELTROMBOPAG eltrombopag 25 mg tablet, 28 (PI, CMI)	3	84	5	$3,733.23	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Public
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14120EMP	ELTROMBOPAG eltrombopag 25 mg tablet, 28 (PI, CMI)	3	84	5	$3,684.36	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Public
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14121FMP	ELTROMBOPAG eltrombopag 50 mg tablet, 28 (PI, CMI)	3	84	3	$7,368.72	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Private
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14127MMP	ELTROMBOPAG eltrombopag 50 mg tablet, 28 (PI, CMI)	3	84	5	$7,417.59	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Public
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14128NMP	ELTROMBOPAG eltrombopag 25 mg tablet, 28 (PI, CMI)	3	84	5	$3,684.36	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Public
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14131RMP	ELTROMBOPAG eltrombopag 50 mg tablet, 28 (PI, CMI)	3	84	5	$7,368.72	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Private
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14136BMP	ELTROMBOPAG eltrombopag 25 mg tablet, 28 (PI, CMI)	3	84	5	$3,733.23	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Private
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14143JMP	ELTROMBOPAG eltrombopag 50 mg tablet, 28 (PI, CMI)	3	84	5	$7,417.59	$25.00	$25.00
	Available brands
	Revolade

Source	S100 HSD Public
Body System	BLOOD AND BLOOD FORMING ORGANS > ANTIHEMORRHAGICS > VITAMIN K AND OTHER HEMOSTATICS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14144KMP	ELTROMBOPAG eltrombopag 25 mg tablet, 28 (PI, CMI)	3	84	3	$3,684.36	$25.00	$25.00
	Available brands
	Revolade