PEGFILGRASTIM

PEGFILGRASTIM (6363X)

pegfilgrastim 6 mg/0.6 mL injection, 0.6 mL syringe
6363X
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9235)

Indication: Chemotherapy-induced neutropenia

Restriction (Streamlined authority code: 9303)

Indication: Chemotherapy-induced neutropenia
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: 11 DPMQ: $90.40 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pelgraz
Ziextenzo

PEGFILGRASTIM (9514R)

pegfilgrastim 6 mg/0.6 mL injection, 0.6 mL syringe
9514R
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7822)

Indication: Chemotherapy-induced neutropenia

Restriction (Streamlined authority code: 7843)

Indication: Chemotherapy-induced neutropenia
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: 11 DPMQ: $77.52 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pelgraz
Ziextenzo