VALACICLOVIR
Manner of administration:Oral
Restriction (Streamlined authority code: 5940)
Indication: Recurrent moderate to severe genital herpes
Treatment phase: Suppressive therapy
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
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| Max qty packs: 1 | Max qty units: 30 | # of repeats: 5 | DPMQ: $26.69 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $29.12 | Max safety net: $25.00 | General Patient Charge: $27.43 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 9267)
Indication: Cytomegalovirus infection and disease
Treatment phase: Prophylaxis
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 5 | Max qty units: 500 | # of repeats: 2 | DPMQ: $216.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $230.93 | Max safety net: $25.00 | General Patient Charge: $39.05 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 5962)
Indication: Herpes zoster
Restriction (Streamlined authority code: 5968)
Indication: Herpes zoster ophthalmicus
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
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| Max qty packs: 1 | Max qty units: 42 | # of repeats: 0 | DPMQ: $31.85 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $34.28 | Max safety net: $25.00 | General Patient Charge: $27.43 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 5960)
Indication: Initial moderate to severe genital herpes
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
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| Max qty packs: 2 | Max qty units: 20 | # of repeats: 0 | DPMQ: $22.40 | Max safety net: $23.88 | General Patient Charge: $25.00 |
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DPMQ: $27.80 | Max safety net: $23.88 | General Patient Charge: $30.40 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 5961)
Indication: Recurrent moderate to severe genital herpes
Treatment phase: Episodic treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 30 | # of repeats: 5 | DPMQ: $26.69 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $29.12 | Max safety net: $25.00 | General Patient Charge: $27.43 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 5975)
Indication: Cytomegalovirus infection and disease
Treatment phase: Prophylaxis
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 5 | Max qty units: 500 | # of repeats: 2 | DPMQ: $200.00 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $213.50 | Max safety net: $25.00 | General Patient Charge: $38.50 | ||