RIVAROXABAN
Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 4132)
Indication: Prevention of recurrent venous thromboembolism
Treatment phase: Continuing treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
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| Max qty packs: 1 | Max qty units: 30 | # of repeats: 5 | DPMQ: $38.28 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
Restriction (Streamlined authority code: 14300)
Indication: Prevention of recurrent venous thromboembolism
Treatment phase: Continuing treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 60 | # of repeats: 5 | DPMQ: $62.78 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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Body System:
Manner of administration:Oral
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: 30 | # of repeats: 0 | DPMQ: $38.28 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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