RIVAROXABAN
Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 14264)
Indication: Deep vein thrombosis
Treatment phase: Continuing treatment
Restriction (Streamlined authority code: 14300)
Indication: Prevention of recurrent venous thromboembolism
Treatment phase: Continuing treatment
Restriction (Streamlined authority code: 14318)
Indication: Pulmonary embolism
Treatment phase: Continuing treatment
Restriction (Streamlined authority code: 14301)
Indication: Prevention of stroke or systemic embolism
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 56 | # of repeats: 5 | DPMQ: $56.40 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 4099)
Indication: Deep vein thrombosis
Treatment phase: Continuing treatment
Restriction (Streamlined authority code: 4132)
Indication: Prevention of recurrent venous thromboembolism
Treatment phase: Continuing treatment
Restriction (Streamlined authority code: 4268)
Indication: Pulmonary embolism
Treatment phase: Continuing treatment
Restriction (Streamlined authority code: 4269)
Indication: Prevention of stroke or systemic embolism
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 28 | # of repeats: 5 | DPMQ: $35.09 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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