ACICLOVIR
Manner of administration:Oral
Restriction (Streamlined authority code: 5942)
Indication: Recurrent moderate to severe genital herpes
Treatment phase: Episodic treatment or suppressive therapy
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 90 | # of repeats: 5 | DPMQ: $31.98 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Manner of administration:Oral
Restriction (Streamlined authority code: 5967)
Indication: Herpes zoster
Restriction (Streamlined authority code: 5959)
Indication: Herpes zoster ophthalmicus
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 35 | # of repeats: 0 | DPMQ: $35.81 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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