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 |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 30 | # of repeats: 5 | DPMQ: $26.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
DPMQ: $29.23 | Max safety net: $25.00 | General Patient Charge: $27.35 | ||
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: $217.24 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
|
|
|||||
|
|
|||||
|
|
DPMQ: $231.29 | 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 |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 42 | # of repeats: 0 | DPMQ: $31.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
DPMQ: $34.24 | Max safety net: $25.00 | General Patient Charge: $27.36 | ||
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 |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 20 | # of repeats: 0 | DPMQ: $22.84 | Max safety net: $24.38 | General Patient Charge: $25.00 |
| Available brands | |||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
DPMQ: $27.94 | Max safety net: $24.38 | General Patient Charge: $30.10 | ||
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: $26.88 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
|||||
|
|
DPMQ: $29.23 | Max safety net: $25.00 | General Patient Charge: $27.35 | ||
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 |
| Available brands | |||||
|
|
|||||
|
|
|||||
|
|
DPMQ: $213.50 | Max safety net: $25.00 | General Patient Charge: $38.50 | ||