TRIMETHOPRIM + SULFAMETHOXAZOLE

TRIMETHOPRIM + SULFAMETHOXAZOLE (10784N)

trimethoprim 160 mg + sulfamethoxazole 800 mg tablet, 10
10784N
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6201)

Indication: Prophylaxis of Pneumocystis jiroveci pneumonia
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 30 # of repeats: 2 DPMQ: $21.87 Max safety net: $23.35 General Patient Charge: $25.00
Available brands
Bactrim DS
Resprim Forte
Septrin Forte
*Additional charge for this brand is $12.51
 DPMQ: $34.38 Max safety net: $23.35 General Patient Charge: $37.51

TRIMETHOPRIM + SULFAMETHOXAZOLE (2951H)

trimethoprim 160 mg + sulfamethoxazole 800 mg tablet, 10
2951H
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: 10 # of repeats: 1 DPMQ: $16.48 Max safety net: $17.96 General Patient Charge: $20.75
Available brands
Bactrim DS
Resprim Forte
Septrin Forte
*Additional charge for this brand is $4.17
 DPMQ: $20.65 Max safety net: $17.96 General Patient Charge: $24.92

TRIMETHOPRIM + SULFAMETHOXAZOLE (3103H)

trimethoprim 40 mg/5 mL + sulfamethoxazole 200 mg/5 mL oral liquid, 100 mL
3103H
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: 1 # of repeats: 1 DPMQ: $22.09 Max safety net: $23.57 General Patient Charge: $25.00
Available brands
Septrin

TRIMETHOPRIM + SULFAMETHOXAZOLE (3390K)

trimethoprim 160 mg + sulfamethoxazole 800 mg tablet, 10
3390K
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: 10 # of repeats: 0 DPMQ: $16.48 Max safety net: $17.96 General Patient Charge: $20.75
Available brands
Bactrim DS
Resprim Forte
Septrin Forte
*Additional charge for this brand is $4.17
 DPMQ: $20.65 Max safety net: $17.96 General Patient Charge: $24.92

TRIMETHOPRIM + SULFAMETHOXAZOLE (3391L)

trimethoprim 40 mg/5 mL + sulfamethoxazole 200 mg/5 mL oral liquid, 100 mL
3391L
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: 1 # of repeats: 0 DPMQ: $22.09 Max safety net: $23.57 General Patient Charge: $25.00
Available brands
Septrin