SOFOSBUVIR + VELPATASVIR

SOFOSBUVIR + VELPATASVIR (11144M)

sofosbuvir 400 mg + velpatasvir 100 mg tablet, 28
11144M
Body System:
Manner of administration:Oral
Private
S100 HSD Private
Authority Required

Restriction

Indication: Chronic hepatitis C infection
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: 2 DPMQ: $11,923.88 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Epclusa

SOFOSBUVIR + VELPATASVIR (11145N)

sofosbuvir 400 mg + velpatasvir 100 mg tablet, 28
11145N
Body System:
Manner of administration:Oral
Public
S100 HSD Public
Authority Required

Restriction

Indication: Chronic hepatitis C infection
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: 2 DPMQ: $11,875.00 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Epclusa

SOFOSBUVIR + VELPATASVIR (11147Q)

sofosbuvir 400 mg + velpatasvir 100 mg tablet, 28
11147Q
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Chronic hepatitis C infection
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: 2 DPMQ: $12,037.93 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Epclusa