LEUPRORELIN (&) BICALUTAMIDE
leuprorelin acetate 7.5 mg modified release injection [1 syringe] (&) inert substance
diluent [1 syringe] (&) bicalutamide 50 mg tablet [28], 1 pack
Manner of administration:Injection/oral
Restriction
Indication: Carcinoma of the prostate
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 5 | DPMQ: $418.09 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bi ELIGARD CP | |||||
leuprorelin acetate 22.5 mg modified release injection [1 syringe] (&) inert substance
diluent [1 syringe] (&) bicalutamide 50 mg tablet [28], 1 pack
Manner of administration:Injection/oral
Restriction
Indication: Carcinoma of the prostate
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $977.04 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bi ELIGARD CP | |||||
leuprorelin acetate 22.5 mg modified release injection [1 syringe] (&) inert substance
diluent [1 syringe] (&) bicalutamide 50 mg tablet [84], 1 pack
Manner of administration:Injection/oral
Restriction
Indication: Carcinoma of the prostate
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 1 | DPMQ: $1,110.04 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bi ELIGARD CP | |||||