METHOXSALEN

METHOXSALEN (12154Q)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12154Q
Body System:
Manner of administration:Extracorporeal Circulation
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10988)

Indication: Erythrodermic stage III-IVa T4 M0 Cutaneous T-cell lymphoma
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 0.08333333 Max qty units: 1 # of repeats: 5 DPMQ: $198.49 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex

METHOXSALEN (12156T)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12156T
Body System:
Manner of administration:Extracorporeal Circulation
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10985)

Indication: Erythrodermic stage III-IVa T4 M0 Cutaneous T-cell lymphoma
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 0.16666667000000002 Max qty units: 2 # of repeats: 6 DPMQ: $396.99 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex

METHOXSALEN (12162D)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12162D
Body System:
Manner of administration:Extracorporeal Circulation
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10971)

Indication: Erythrodermic stage III-IVa T4 M0 Cutaneous T-cell lymphoma
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 0.16666667000000002 Max qty units: 2 # of repeats: 6 DPMQ: $421.75 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex

METHOXSALEN (12173Q)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12173Q
Body System:
Manner of administration:Extracorporeal Circulation
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10989)

Indication: Erythrodermic stage III-IVa T4 M0 Cutaneous T-cell lymphoma
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 0.08333333 Max qty units: 1 # of repeats: 5 DPMQ: $215.31 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex

METHOXSALEN (12839R)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12839R
Body System:
Manner of administration:Extracorporeal Circulation
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 12567)

Indication: Chronic graft versus host disease
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 0.16666667000000002 Max qty units: 2 # of repeats: 0 DPMQ: $421.75 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex

METHOXSALEN (12854M)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12854M
Body System:
Manner of administration:Extracorporeal Circulation
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 12531)

Indication: Chronic graft versus host disease
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 0.16666667000000002 Max qty units: 2 # of repeats: 0 DPMQ: $396.99 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex

METHOXSALEN (12855N)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12855N
Body System:
Manner of administration:Extracorporeal Circulation
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 12579)

Indication: Chronic graft versus host disease
Treatment phase: Initial treatment in a treatment episode
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 12 # of repeats: 1 DPMQ: $2,430.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex

METHOXSALEN (12876Q)

methoxsalen 200 microgram/10 mL injection, 12 x 10 mL vials
12876Q
Body System:
Manner of administration:Extracorporeal Circulation
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 12546)

Indication: Chronic graft versus host disease
Treatment phase: Initial treatment in a treatment episode
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 12 # of repeats: 1 DPMQ: $2,381.92 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Uvadex