TEDUGLUTIDE
teduglutide 5 mg injection [28 vials] (&) inert substance diluent [28 x 0.5 mL syringes],
1 pack
Manner of administration:Injection
Restriction
Indication: Type III Short bowel syndrome with intestinal failure
Treatment phase: Initial 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: 28 | # of repeats: 11 | DPMQ: $19,710.60 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Revestive | |||||
teduglutide 5 mg injection [28 vials] (&) inert substance diluent [28 x 0.5 mL syringes],
1 pack
Manner of administration:Injection
Restriction
Indication: Type III Short bowel syndrome with intestinal failure
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: 28 | # of repeats: 5 | DPMQ: $19,710.60 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Revestive | |||||
teduglutide 5 mg injection [28 vials] (&) inert substance diluent [28 x 0.5 mL syringes],
1 pack
Manner of administration:Injection
Restriction
Indication: Type III Short bowel syndrome with intestinal failure
Treatment phase: Initial 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: 28 | # of repeats: 11 | DPMQ: $19,759.48 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Revestive | |||||
teduglutide 5 mg injection [28 vials] (&) inert substance diluent [28 x 0.5 mL syringes],
1 pack
Manner of administration:Injection
Restriction
Indication: Type III Short bowel syndrome with intestinal failure
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: 28 | # of repeats: 5 | DPMQ: $19,759.48 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Revestive | |||||
teduglutide 5 mg injection [28 vials] (&) inert substance diluent [28 x 0.5 mL syringes],
1 pack
Manner of administration:Injection
Restriction
Indication: Type III Short bowel syndrome with intestinal failure
Treatment phase: Initial treatment - balance of supply
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: 0 | DPMQ: $19,710.60 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Revestive | |||||
teduglutide 5 mg injection [28 vials] (&) inert substance diluent [28 x 0.5 mL syringes],
1 pack
Manner of administration:Injection
Restriction
Indication: Type III Short bowel syndrome with intestinal failure
Treatment phase: Initial treatment - balance of supply
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: 0 | DPMQ: $19,759.48 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Revestive | |||||