PRALATREXATE

PRALATREXATE (11271F)

pralatrexate 20 mg/mL injection, 1 mL vial
11271F
Body System:
Manner of administration:Injection
Private
Chemotherapy Items for Private Hospital use
Authority Required

Restriction

Indication: Relapsed or chemotherapy refractory Peripheral T-cell Lymphoma
Treatment phase: Initial treatment
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 80 mg # of repeats: 5 DPMA: $4,336.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Folotyn
(pralatrexate 20 mg/mL injection, 1 mL vial)

PRALATREXATE (11272G)

pralatrexate 20 mg/mL injection, 1 mL vial
11272G
Body System:
Manner of administration:Injection
Public
Chemotherapy Items for Public Hospital use
Authority Required

Restriction

Indication: Relapsed or chemotherapy refractory Peripheral T-cell Lymphoma
Treatment phase: Continuing treatment
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 80 mg # of repeats: 11 DPMA: $4,233.23 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Folotyn
(pralatrexate 20 mg/mL injection, 1 mL vial)

PRALATREXATE (11278N)

pralatrexate 20 mg/mL injection, 1 mL vial
11278N
Body System:
Manner of administration:Injection
Private
Chemotherapy Items for Private Hospital use
Authority Required

Restriction

Indication: Relapsed or chemotherapy refractory Peripheral T-cell Lymphoma
Treatment phase: Continuing treatment
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 80 mg # of repeats: 11 DPMA: $4,336.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Folotyn
(pralatrexate 20 mg/mL injection, 1 mL vial)

PRALATREXATE (11293J)

pralatrexate 20 mg/mL injection, 1 mL vial
11293J
Body System:
Manner of administration:Injection
Public
Chemotherapy Items for Public Hospital use
Authority Required

Restriction

Indication: Relapsed or chemotherapy refractory Peripheral T-cell Lymphoma
Treatment phase: Initial treatment
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 80 mg # of repeats: 5 DPMA: $4,233.23 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Folotyn
(pralatrexate 20 mg/mL injection, 1 mL vial)