PALBOCICLIB

PALBOCICLIB (12818P)

palbociclib 75 mg tablet, 21
12818P
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Locally advanced or metastatic breast cancer
Treatment phase: Initial treatment

Restriction

Indication: Locally advanced or metastatic breast cancer
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: 21 # of repeats: 5 DPMQ: $3,658.05 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ibrance

PALBOCICLIB (12819Q)

palbociclib 100 mg tablet, 21
12819Q
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Locally advanced or metastatic breast cancer
Treatment phase: Initial treatment

Restriction

Indication: Locally advanced or metastatic breast cancer
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: 21 # of repeats: 5 DPMQ: $3,658.05 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ibrance

PALBOCICLIB (12822W)

palbociclib 125 mg tablet, 21
12822W
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Locally advanced or metastatic breast cancer
Treatment phase: Initial treatment

Restriction

Indication: Locally advanced or metastatic breast cancer
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: 21 # of repeats: 5 DPMQ: $3,658.05 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ibrance