TRIMETHOPRIM

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Prostatitis

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 4	Max qty units: 28	# of repeats: 0	DPMQ: $24.56	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
TRIMETHOPRIM-WGR
Trimethoprim Viatris
Alprim *Additional charge for this brand is $11.04			DPMQ: $35.60	Max safety net: $25.00	General Patient Charge: $36.04
Triprim *Additional charge for this brand is $15.92			DPMQ: $40.48	Max safety net: $25.00	General Patient Charge: $40.92

Body System:

Manner of administration:Oral

General Schedule

Authority Required (STREAMLINED)

Indication: Prophylaxis of urinary tract infection

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 2	Max qty units: 14	# of repeats: 2	DPMQ: $19.18	Max safety net: $20.66	General Patient Charge: $23.45
Available brands
TRIMETHOPRIM-WGR
Trimethoprim Viatris
Alprim *Additional charge for this brand is $5.52			DPMQ: $24.70	Max safety net: $20.66	General Patient Charge: $28.97
Triprim *Additional charge for this brand is $7.96			DPMQ: $27.14	Max safety net: $20.66	General Patient Charge: $31.41

Body System:

Manner of administration:Oral

General Schedule

No restrictions

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 7	# of repeats: 1	DPMQ: $16.48	Max safety net: $17.96	General Patient Charge: $20.75
Available brands
TRIMETHOPRIM-WGR
Trimethoprim Viatris
Alprim *Additional charge for this brand is $2.76			DPMQ: $19.24	Max safety net: $17.96	General Patient Charge: $23.51
Triprim *Additional charge for this brand is $3.98			DPMQ: $20.46	Max safety net: $17.96	General Patient Charge: $24.73

TRIMETHOPRIM (10785P)