EMPAGLIFLOZIN

EMPAGLIFLOZIN (10202Y)

empagliflozin 25 mg tablet, 30
10202Y
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: 30 # of repeats: 5 DPMQ: $55.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Jardiance

EMPAGLIFLOZIN (13920P)

empagliflozin 25 mg tablet, 30
13920P
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: 60 # of repeats: 5 DPMQ: $98.14 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Jardiance