AXITINIB

AXITINIB (10539Q)

axitinib 1 mg tablet, 28
10539Q
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7433)

Indication: Stage IV clear cell variant renal cell carcinoma (RCC)
Treatment phase: Continuing treatment beyond 3 months
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: $1,020.84 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Inlyta

AXITINIB (10540R)

axitinib 5 mg tablet, 28
10540R
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Stage IV clear cell variant renal cell carcinoma (RCC)
Treatment phase: Initial treatment
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: 2 DPMQ: $4,711.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Inlyta

AXITINIB (10556N)

axitinib 5 mg tablet, 28
10556N
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7433)

Indication: Stage IV clear cell variant renal cell carcinoma (RCC)
Treatment phase: Continuing treatment beyond 3 months
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: $4,711.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Inlyta

AXITINIB (10572K)

axitinib 1 mg tablet, 28
10572K
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Stage IV clear cell variant renal cell carcinoma (RCC)
Treatment phase: Initial treatment
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: 2 DPMQ: $1,020.84 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Inlyta