DAPAGLIFLOZIN

DAPAGLIFLOZIN (10011X)

dapagliflozin 10 mg tablet, 28
10011X
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16220)

Indication: Diabetes mellitus type 2

Restriction (Streamlined authority code: 15311)

Indication: Diabetes mellitus type 2
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $52.95 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga

DAPAGLIFLOZIN (12823X)

dapagliflozin 10 mg tablet, 28
12823X
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15047)

Indication: Chronic heart failure
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $52.95 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga

DAPAGLIFLOZIN (13106T)

dapagliflozin 10 mg tablet, 28
13106T
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18624)

Indication: Chronic kidney disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $52.95 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga

DAPAGLIFLOZIN (13844P)

dapagliflozin 10 mg tablet, 28
13844P
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16164)

Indication: Diabetes mellitus type 2

Restriction (Streamlined authority code: 15265)

Indication: Diabetes mellitus type 2
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 56 # of repeats: 5 DPMQ: $92.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga

DAPAGLIFLOZIN (14054Q)

dapagliflozin 10 mg tablet, 28
14054Q
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15051)

Indication: Chronic heart failure
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 56 # of repeats: 5 DPMQ: $92.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga

DAPAGLIFLOZIN (14073Q)

dapagliflozin 10 mg tablet, 28
14073Q
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 14471)

Indication: Chronic heart failure
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $52.95 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga

DAPAGLIFLOZIN (15257B)

dapagliflozin 10 mg tablet, 28
15257B
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18623)

Indication: Chronic kidney disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 56 # of repeats: 5 DPMQ: $92.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga

DAPAGLIFLOZIN (15353C)

dapagliflozin 10 mg tablet, 28
15353C
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18113)

Indication: Chronic heart failure
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 56 # of repeats: 5 DPMQ: $92.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Forxiga