RALOXIFENE

RALOXIFENE (13426P)

raloxifene hydrochloride 60 mg tablet, 28
13426P
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 14274)

Indication: Established post-menopausal osteoporosis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 56 # of repeats: 5 DPMQ: $47.48 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Fixta 60
RALOVISTA
Raloxifene GH
Evista
*Additional charge for this brand is $8.18
 DPMQ: $55.66 Max safety net: $25.00 General Patient Charge: $33.18

RALOXIFENE (8363E)

raloxifene hydrochloride 60 mg tablet, 28
8363E
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6314)

Indication: Established post-menopausal osteoporosis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $30.63 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Fixta 60
RALOVISTA
Raloxifene GH
Evista
*Additional charge for this brand is $4.09
 DPMQ: $34.72 Max safety net: $25.00 General Patient Charge: $29.09