GLATIRAMER ACETATE

GLATIRAMER ACETATE (10416F)

glatiramer acetate 40 mg/mL injection, 12 x 1 mL syringes
10416F
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16321)

Indication: Multiple sclerosis
Treatment phase: Initial treatment

Restriction (Streamlined authority code: 16297)

Indication: Multiple sclerosis
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: 12 # of repeats: 5 DPMQ: $563.85 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Copaxone
Glatira

GLATIRAMER ACETATE (13110B)

glatiramer acetate 40 mg/mL injection, 12 x 1 mL pen devices
13110B
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16321)

Indication: Multiple sclerosis
Treatment phase: Initial treatment

Restriction (Streamlined authority code: 16297)

Indication: Multiple sclerosis
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: 12 # of repeats: 5 DPMQ: $599.19 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Copaxone