GANCICLOVIR

GANCICLOVIR (10328N)

ganciclovir 500 mg injection, 5 vials
10328N
Body System:
Manner of administration:Injection
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5000)

Indication: Cytomegalovirus retinitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 10 # of repeats: 1 DPMQ: $250.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cymevene
GANCICLOVIR SXP

GANCICLOVIR (5749N)

ganciclovir 500 mg injection, 5 vials
5749N
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15800)

Indication: Cytomegalovirus infection and disease

Restriction (Streamlined authority code: 15814)

Indication: Cytomegalovirus infection and 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: 10 # of repeats: 1 DPMQ: $232.18 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cymevene
GANCICLOVIR SXP

GANCICLOVIR (6136Y)

ganciclovir 500 mg injection, 5 vials
6136Y
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15784)

Indication: Cytomegalovirus infection and disease

Restriction (Streamlined authority code: 15782)

Indication: Cytomegalovirus infection and 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: 10 # of repeats: 1 DPMQ: $250.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cymevene
GANCICLOVIR SXP