TEZACAFTOR + IVACAFTOR (&) IVACAFTOR
tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28],
56
Manner of administration:Oral
Restriction
Indication: Cystic fibrosis - one residual function (RF) mutation
Treatment phase: Initial treatment
Restriction
Indication: Cystic fibrosis - one residual function (RF) mutation
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: 1 | # of repeats: 5 | DPMQ: $19,001.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Symdeko | |||||
tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28],
56
Manner of administration:Oral
Restriction
Indication: Cystic fibrosis - homozygous for the F508del mutation
Treatment phase: Initial treatment
Restriction
Indication: Cystic fibrosis - homozygous for the F508del mutation
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: 1 | # of repeats: 5 | DPMQ: $19,001.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Symdeko | |||||
tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28],
56
Manner of administration:Oral
Restriction
Indication: Cystic fibrosis - homozygous for the F508del mutation
Treatment phase: Initial treatment
Restriction
Indication: Cystic fibrosis - homozygous for the F508del mutation
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: 1 | # of repeats: 5 | DPMQ: $18,952.50 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Symdeko | |||||
tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28],
56
Manner of administration:Oral
Restriction
Indication: Cystic fibrosis - one residual function (RF) mutation
Treatment phase: Initial treatment
Restriction
Indication: Cystic fibrosis - one residual function (RF) mutation
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: 1 | # of repeats: 5 | DPMQ: $18,952.50 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Symdeko | |||||