EDARAVONE

EDARAVONE (14804E)

Supply only until 01/07/2026
edaravone 30 mg/20 mL injection, 10 x 20 mL ampoules
14804E
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required

Restriction

Indication: Amyotrophic lateral sclerosis
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2.8000000000000003 Max qty units: 28 # of repeats: 0 DPMQ: $6,208.89 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Radicava

EDARAVONE (14805F)

Supply only until 01/07/2026
edaravone 30 mg/20 mL injection, 10 x 20 mL ampoules
14805F
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required

Restriction

Indication: Amyotrophic lateral sclerosis
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2.8000000000000003 Max qty units: 28 # of repeats: 0 DPMQ: $6,160.00 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Radicava

EDARAVONE (14806G)

edaravone 30 mg/20 mL injection, 10 x 20 mL ampoules
14806G
Body System:
Manner of administration:Injection
S100 HSD Community Access
Authority Required

Restriction

Indication: Amyotrophic lateral 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: 2 Max qty units: 20 # of repeats: 2 DPMQ: $4,448.88 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Radicava

EDARAVONE (15334C)

edaravone 30 mg/20 mL injection, 10 x 20 mL ampoules
15334C
Body System:
Manner of administration:Injection
S100 HSD Community Access
Authority Required

Restriction

Indication: Amyotrophic lateral sclerosis
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2.8000000000000003 Max qty units: 28 # of repeats: 0 DPMQ: $6,208.89 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Radicava