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: $25.32	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
TRIMETHOPRIM-WGR
Trimethoprim Viatris
Alprim *Additional charge for this brand is $10.28			DPMQ: $35.60	Max safety net: $25.00	General Patient Charge: $35.28
Triprim *Additional charge for this brand is $14.92			DPMQ: $40.24	Max safety net: $25.00	General Patient Charge: $39.92

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: $19.84	Max safety net: $21.38	General Patient Charge: $24.17
Available brands
TRIMETHOPRIM-WGR
Trimethoprim Viatris
Alprim *Additional charge for this brand is $5.14			DPMQ: $24.98	Max safety net: $21.38	General Patient Charge: $29.31
Triprim *Additional charge for this brand is $7.46			DPMQ: $27.30	Max safety net: $21.38	General Patient Charge: $31.63

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: $17.10	Max safety net: $18.64	General Patient Charge: $21.43
Available brands
TRIMETHOPRIM-WGR
Trimethoprim Viatris
Alprim *Additional charge for this brand is $2.57			DPMQ: $19.67	Max safety net: $18.64	General Patient Charge: $24.00
Triprim *Additional charge for this brand is $3.73			DPMQ: $20.83	Max safety net: $18.64	General Patient Charge: $25.16

TRIMETHOPRIM (10785P)