SUMATRIPTAN

SUMATRIPTAN (10694W)

SUMATRIPTAN Tablet 50 mg (base) (fast disintegrating), 4
10694W
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Migraine attack
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 4 # of repeats: 5 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Imigran FDT
*Additional charge for this brand is $4.19
 DPMQ: $24.22 Max safety net: $21.51 General Patient Charge: $28.49

SUMATRIPTAN (1849H)

sumatriptan 50 mg tablet, 4
1849H
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Migraine attack
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 4 # of repeats: 5 DPMQ: $20.03 Max safety net: $21.51 General Patient Charge: $24.30
Available brands
APO-Sumatriptan
Iptam
Pharmacor Sumatriptan 50
SUMATRIPTAN-WGR
Sumatran
Sumatriptan Sandoz
Sumatriptan generichealth
Imigran
*Additional charge for this brand is $4.19
 DPMQ: $24.22 Max safety net: $21.51 General Patient Charge: $28.49

SUMATRIPTAN (8144P)

sumatriptan 50 mg tablet, 2
8144P
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Migraine attack
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 4 # of repeats: 5 DPMQ: $20.04 Max safety net: $21.52 General Patient Charge: $24.31
Available brands
APO-Sumatriptan
Iptam
Sumagraine Migraine Relief
Sumatran