DABIGATRAN

Body System:

Manner of administration:Oral

General Schedule

Authority Required (STREAMLINED)

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: $72.76	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 $14.78			DPMQ: $87.54	Max safety net: $25.00	General Patient Charge: $39.78

Body System:

Manner of administration:Oral

General Schedule

Authority Required (STREAMLINED)

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: $43.27	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 $7.39			DPMQ: $50.66	Max safety net: $25.00	General Patient Charge: $32.39

Body System:

Manner of administration:Oral

General Schedule

Authority Required (STREAMLINED)

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: $43.27	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 $7.39			DPMQ: $50.66	Max safety net: $25.00	General Patient Charge: $32.39

DABIGATRAN (13523R)