EXEMESTANE

EXEMESTANE (10103R)

exemestane 25 mg tablet, 30
10103R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Metastatic (Stage IV) breast cancer
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: $51.63 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Exemestane
EXEMESTANE-WGR
Exemestane GH
Exemestane Sandoz
Aromasin
*Additional charge for this brand is $2.73
 DPMQ: $54.36 Max safety net: $25.00 General Patient Charge: $27.73

EXEMESTANE (13857H)

exemestane 25 mg tablet, 30
13857H
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Breast cancer
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $89.48 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Exemestane
EXEMESTANE-WGR
Exemestane GH
Exemestane Sandoz
Aromasin
*Additional charge for this brand is $5.46
 DPMQ: $94.94 Max safety net: $25.00 General Patient Charge: $30.46

EXEMESTANE (14036R)

exemestane 25 mg tablet, 30
14036R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Metastatic (Stage IV) breast cancer
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $89.48 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Exemestane
EXEMESTANE-WGR
Exemestane GH
Exemestane Sandoz
Aromasin
*Additional charge for this brand is $5.46
 DPMQ: $94.94 Max safety net: $25.00 General Patient Charge: $30.46

EXEMESTANE (8506Q)

exemestane 25 mg tablet, 30
8506Q
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Breast cancer
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: $51.63 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Exemestane
EXEMESTANE-WGR
Exemestane GH
Exemestane Sandoz
Aromasin
*Additional charge for this brand is $2.73
 DPMQ: $54.36 Max safety net: $25.00 General Patient Charge: $27.73