RALTEGRAVIR

RALTEGRAVIR (10286J)

raltegravir 400 mg tablet, 60
10286J
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4512)

Indication: HIV infection
Treatment phase: Initial

Restriction (Streamlined authority code: 4454)

Indication: HIV infection
Treatment phase: Continuing
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 120 # of repeats: 5 DPMQ: $883.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Isentress

RALTEGRAVIR (11248B)

raltegravir 600 mg tablet, 60
11248B
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4512)

Indication: HIV infection
Treatment phase: Initial

Restriction (Streamlined authority code: 4454)

Indication: HIV infection
Treatment phase: Continuing
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 120 # of repeats: 5 DPMQ: $883.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Isentress HD