LACOSAMIDE
Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 17455)
Indication: Intractable focal onset seizures
Treatment phase: Continuing treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 56 | # of repeats: 5 | DPMQ: $38.16 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 17513)
Indication: Idiopathic generalised epilepsy with primary generalised tonic-clonic seizures
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 56 | # of repeats: 5 | DPMQ: $38.16 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 17560)
Indication: Intractable focal onset seizures
Treatment phase: Continuing treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 112 | # of repeats: 5 | DPMQ: $61.96 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 17516)
Indication: Idiopathic generalised epilepsy with primary generalised tonic-clonic seizures
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 112 | # of repeats: 5 | DPMQ: $61.96 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 17541)
Indication: Intractable focal onset seizures
Treatment phase: Initial treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 14 | # of repeats: 1 | DPMQ: $20.31 | Max safety net: $21.85 | General Patient Charge: $24.64 |
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