RASAGILINE

RASAGILINE (14458Y)

rasagiline 1 mg tablet, 30
14458Y
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $45.14 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Alziras
Pharmacor Rasagiline
Rasagiline Lupin
Rasagiline Sandoz
Rasagiline-Teva
Azilect
*Additional charge for this brand is $4.00
 DPMQ: $49.14 Max safety net: $25.00 General Patient Charge: $29.00

RASAGILINE (1952R)

rasagiline 1 mg tablet, 30
1952R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 30 # of repeats: 5 DPMQ: $29.46 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Alziras
Pharmacor Rasagiline
Rasagiline Lupin
Rasagiline Sandoz
Rasagiline-Teva
Azilect
*Additional charge for this brand is $2.00
 DPMQ: $31.46 Max safety net: $25.00 General Patient Charge: $27.00