LUMACAFTOR + IVACAFTOR

LUMACAFTOR + IVACAFTOR (11464J)

lumacaftor 100 mg + ivacaftor 125 mg tablet, 112
11464J
Body System:
Manner of administration:Oral
Private
S100 HSD Private
Authority Required

Restriction

Indication: Cystic fibrosis
Treatment phase: Initial treatment

Restriction

Indication: Cystic fibrosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 112 # of repeats: 5 DPMQ: $16,970.76 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Orkambi

LUMACAFTOR + IVACAFTOR (11465K)

lumacaftor 100 mg + ivacaftor 125 mg tablet, 112
11465K
Body System:
Manner of administration:Oral
Public
S100 HSD Public
Authority Required

Restriction

Indication: Cystic fibrosis
Treatment phase: Initial treatment

Restriction

Indication: Cystic fibrosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 112 # of repeats: 5 DPMQ: $16,921.88 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Orkambi