DABIGATRAN

DABIGATRAN (13489Y)

dabigatran etexilate 150 mg capsule, 60
13489Y
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 14301)

Indication: Prevention of stroke or systemic embolism
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: $71.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Sandoz
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa
*Additional charge for this brand is $14.32
 DPMQ: $85.44 Max safety net: $25.00 General Patient Charge: $39.32

DABIGATRAN (13523R)

dabigatran etexilate 110 mg capsule, 60
13523R
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 14301)

Indication: Prevention of stroke or systemic embolism
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: $71.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Sandoz
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa
*Additional charge for this brand is $14.32
 DPMQ: $85.88 Max safety net: $25.00 General Patient Charge: $39.32

DABIGATRAN (2753X)

dabigatran etexilate 110 mg capsule, 60
2753X
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4269)

Indication: Prevention of stroke or systemic embolism
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: $42.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Sandoz
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa
*Additional charge for this brand is $7.16
 DPMQ: $50.12 Max safety net: $25.00 General Patient Charge: $32.16

DABIGATRAN (2769R)

dabigatran etexilate 150 mg capsule, 60
2769R
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4269)

Indication: Prevention of stroke or systemic embolism
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: $42.74 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Sandoz
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa
*Additional charge for this brand is $7.16
 DPMQ: $49.90 Max safety net: $25.00 General Patient Charge: $32.16

DABIGATRAN (9318K)

dabigatran etexilate 75 mg capsule, 10
9318K
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4369)

Indication: Prevention of venous thromboembolism
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: 1 DPMQ: $32.10 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
PHARMACOR DABIGATRAN

DABIGATRAN (9319L)

dabigatran etexilate 110 mg capsule, 10
9319L
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4369)

Indication: Prevention of venous thromboembolism
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: 1 DPMQ: $23.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pradaxa

DABIGATRAN (9320M)

dabigatran etexilate 75 mg capsule, 60
9320M
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4402)

Indication: Prevention of venous thromboembolism
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: 0 DPMQ: $67.55 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa

DABIGATRAN (9321N)

dabigatran etexilate 110 mg capsule, 60
9321N
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4402)

Indication: Prevention of venous thromboembolism
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: 0 DPMQ: $42.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dabigatran
Dabigatran Sandoz
Dabigatran Viatris
PHARMACOR DABIGATRAN
Pradaxa
*Additional charge for this brand is $7.16
 DPMQ: $50.12 Max safety net: $25.00 General Patient Charge: $32.16

DABIGATRAN (9322P)

dabigatran etexilate 75 mg capsule, 10
9322P
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4381)

Indication: Prevention of venous thromboembolism
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: $32.10 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
PHARMACOR DABIGATRAN

DABIGATRAN (9323Q)

dabigatran etexilate 110 mg capsule, 10
9323Q
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4381)

Indication: Prevention of venous thromboembolism
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: $23.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pradaxa