DORNASE ALFA

DORNASE ALFA (5704F)

dornase alfa 2.5 mg/2.5 mL inhalation solution, 30 x 2.5 mL ampoules
5704F
Body System:
Manner of administration:Inhalation
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5740)

Indication: Cystic fibrosis

Restriction (Streamlined authority code: 5634)

Indication: Cystic fibrosis

Restriction (Streamlined authority code: 5635)

Indication: Cystic fibrosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $1,490.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pulmozyme

DORNASE ALFA (6120D)

dornase alfa 2.5 mg/2.5 mL inhalation solution, 30 x 2.5 mL ampoules
6120D
Body System:
Manner of administration:Inhalation
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9624)

Indication: Cystic fibrosis

Restriction (Streamlined authority code: 9591)

Indication: Cystic fibrosis

Restriction (Streamlined authority code: 9592)

Indication: Cystic fibrosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $1,539.86 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pulmozyme