FLUTICASONE FUROATE + UMECLIDINIUM + VILANTEROL

FLUTICASONE FUROATE + UMECLIDINIUM + VILANTEROL (11379X)

fluticasone furoate 100 microgram/actuation + umeclidinium 62.5 microgram/actuation + vilanterol 25 microgram/actuation powder for inhalation, 30 actuations
11379X
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 12349)

Indication: Chronic obstructive pulmonary disease (COPD)
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: $85.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Trelegy Ellipta 100/62.5/25

FLUTICASONE FUROATE + UMECLIDINIUM + VILANTEROL (12917W)

fluticasone furoate 200 microgram/actuation + umeclidinium 62.5 microgram/actuation + vilanterol 25 microgram/actuation powder for inhalation, 30 actuations
12917W
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 12603)

Indication: Severe asthma
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: $89.39 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Trelegy Ellipta 200/62.5/25

FLUTICASONE FUROATE + UMECLIDINIUM + VILANTEROL (14346C)

fluticasone furoate 100 microgram/actuation + umeclidinium 62.5 microgram/actuation + vilanterol 25 microgram/actuation powder for inhalation, 30 actuations
14346C
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15543)

Indication: Chronic obstructive pulmonary disease (COPD)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 5 DPMQ: $159.76 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Trelegy Ellipta 100/62.5/25

FLUTICASONE FUROATE + UMECLIDINIUM + VILANTEROL (14382Y)

fluticasone furoate 200 microgram/actuation + umeclidinium 62.5 microgram/actuation + vilanterol 25 microgram/actuation powder for inhalation, 30 actuations
14382Y
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15601)

Indication: Severe asthma
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 5 DPMQ: $167.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Trelegy Ellipta 200/62.5/25