EMPAGLIFLOZIN
Manner of administration:Oral
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: $55.74 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||
Manner of administration:Oral
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: 30 | # of repeats: 5 | DPMQ: $55.74 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||
Manner of administration:Oral
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: 30 | # of repeats: 5 | DPMQ: $55.74 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||
Manner of administration:Oral
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: $97.70 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||
Manner of administration:Oral
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: 60 | # of repeats: 5 | DPMQ: $97.70 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||
Manner of administration:Oral
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: 30 | # of repeats: 5 | DPMQ: $55.74 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||
Manner of administration:Oral
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: 60 | # of repeats: 5 | DPMQ: $97.70 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||
Manner of administration:Oral
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: 60 | # of repeats: 5 | DPMQ: $97.70 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jardiance | |||||