DAPAGLIFLOZIN + METFORMIN
dapagliflozin 5 mg + metformin hydrochloride 1 g modified release tablet, 56
Manner of administration:Oral
Restriction (Streamlined authority code: 16158)
Indication: Diabetes mellitus type 2
Restriction (Streamlined authority code: 15289)
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: 56 | # of repeats: 5 | DPMQ: $54.98 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xigduo XR 5/1000 | |||||
dapagliflozin 10 mg + metformin hydrochloride 1 g modified release tablet, 28
Manner of administration:Oral
Restriction (Streamlined authority code: 16158)
Indication: Diabetes mellitus type 2
Restriction (Streamlined authority code: 15289)
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: 28 | # of repeats: 5 | DPMQ: $53.68 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xigduo XR 10/1000 | |||||
dapagliflozin 10 mg + metformin hydrochloride 500 mg modified release tablet, 28
Manner of administration:Oral
Restriction (Streamlined authority code: 16158)
Indication: Diabetes mellitus type 2
Restriction (Streamlined authority code: 15289)
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: 28 | # of repeats: 5 | DPMQ: $52.90 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xigduo XR 10/500 | |||||
dapagliflozin 5 mg + metformin hydrochloride 1 g modified release tablet, 56
Manner of administration:Oral
Restriction (Streamlined authority code: 16162)
Indication: Diabetes mellitus type 2
Restriction (Streamlined authority code: 15267)
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: 112 | # of repeats: 5 | DPMQ: $96.18 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xigduo XR 5/1000 | |||||
dapagliflozin 10 mg + metformin hydrochloride 1 g modified release tablet, 28
Manner of administration:Oral
Restriction (Streamlined authority code: 16162)
Indication: Diabetes mellitus type 2
Restriction (Streamlined authority code: 15267)
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: 56 | # of repeats: 5 | DPMQ: $93.58 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xigduo XR 10/1000 | |||||
dapagliflozin 10 mg + metformin hydrochloride 500 mg modified release tablet, 28
Manner of administration:Oral
Restriction (Streamlined authority code: 16162)
Indication: Diabetes mellitus type 2
Restriction (Streamlined authority code: 15267)
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: 56 | # of repeats: 5 | DPMQ: $92.02 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xigduo XR 10/500 | |||||