FLUTICASONE PROPIONATE + FORMOTEROL
fluticasone propionate 125 microgram/actuation + formoterol fumarate dihydrate 5 microgram/actuation
inhalation, 120 actuations
Manner of administration:Inhalation By Mouth
Restriction (Streamlined authority code: 4395)
Indication: Asthma
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 5 | DPMQ: $40.18 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| flutiform 125/5 | |||||
fluticasone propionate 250 microgram/actuation + formoterol fumarate dihydrate 10
microgram/actuation inhalation, 120 actuations
Manner of administration:Inhalation By Mouth
Restriction (Streamlined authority code: 4395)
Indication: Asthma
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 5 | DPMQ: $51.90 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| flutiform 250/10 | |||||
fluticasone propionate 125 microgram/actuation + formoterol fumarate dihydrate 5 microgram/actuation
inhalation, 120 actuations
Manner of administration:Inhalation By Mouth
Restriction (Streamlined authority code: 15635)
Indication: Asthma
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 2 | # of repeats: 5 | DPMQ: $66.58 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| flutiform 125/5 | |||||
fluticasone propionate 250 microgram/actuation + formoterol fumarate dihydrate 10
microgram/actuation inhalation, 120 actuations
Manner of administration:Inhalation By Mouth
Restriction (Streamlined authority code: 15635)
Indication: Asthma
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 2 | # of repeats: 5 | DPMQ: $90.02 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| flutiform 250/10 | |||||
fluticasone propionate 50 microgram/actuation + formoterol fumarate dihydrate 5 microgram/actuation
inhalation, 120 actuations
Manner of administration:Inhalation By Mouth
Restriction (Streamlined authority code: 15635)
Indication: Asthma
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 2 | # of repeats: 5 | DPMQ: $65.44 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| flutiform 50/5 | |||||
fluticasone propionate 50 microgram/actuation + formoterol fumarate dihydrate 5 microgram/actuation
inhalation, 120 actuations
Manner of administration:Inhalation By Mouth
Restriction (Streamlined authority code: 4395)
Indication: Asthma
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 5 | DPMQ: $39.61 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| flutiform 50/5 | |||||