TOPIRAMATE
Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 17562)
Indication: Seizures
Restriction (Streamlined authority code: 14901)
Indication: Migraine
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 120 | # of repeats: 5 | DPMQ: $25.12 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 17487)
Indication: Seizures
Restriction (Streamlined authority code: 5325)
Indication: Migraine
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 60 | # of repeats: 5 | DPMQ: $19.45 | Max safety net: $20.93 | General Patient Charge: $23.72 |
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