DABIGATRAN

DABIGATRAN (13489Y)

dabigatran etexilate 150 mg capsule, 60
13489Y
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

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: 120 # of repeats: 5 DPMQ: $72.32 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Sandoz
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa
*Additional charge for this brand is $14.74
 DPMQ: $87.06 Max safety net: $25.00 General Patient Charge: $39.74

DABIGATRAN (2769R)

dabigatran etexilate 150 mg capsule, 60
2769R
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

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: 60 # of repeats: 5 DPMQ: $43.05 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Sandoz
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa
*Additional charge for this brand is $7.37
 DPMQ: $50.42 Max safety net: $25.00 General Patient Charge: $32.37