MARIBAVIR

MARIBAVIR (14856X)

maribavir 200 mg tablet, 28
14856X
Body System:
Manner of administration:Oral
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16735)

Indication: Cytomegalovirus infection and disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 112 # of repeats: 1 DPMQ: $28,200.00 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Livtencity

MARIBAVIR (14865J)

maribavir 200 mg tablet, 28
14865J
Body System:
Manner of administration:Oral
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16806)

Indication: Cytomegalovirus infection and disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 112 # of repeats: 1 DPMQ: $28,248.88 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Livtencity

MARIBAVIR (14866K)

maribavir 200 mg tablet, 28
14866K
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16735)

Indication: Cytomegalovirus infection and disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 112 # of repeats: 1 DPMQ: $28,248.88 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Livtencity