Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11097CMP	IVACAFTOR ivacaftor 50 mg granules, 56 sachets (PI, CMI)	1	56	5	$21423.67	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11105LMP	IVACAFTOR ivacaftor 50 mg granules, 56 sachets (PI, CMI)	1	56	5	$21375.00	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11463HMP	LUMACAFTOR + IVACAFTOR lumacaftor 200 mg + ivacaftor 125 mg tablet, 112 (PI, CMI)	1	112	5	$17861.17	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11464JMP	LUMACAFTOR + IVACAFTOR lumacaftor 100 mg + ivacaftor 125 mg tablet, 112 (PI, CMI)	1	112	5	$17861.17	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11465KMP	LUMACAFTOR + IVACAFTOR lumacaftor 100 mg + ivacaftor 125 mg tablet, 112 (PI, CMI)	1	112	5	$17812.50	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11466LMP	LUMACAFTOR + IVACAFTOR lumacaftor 200 mg + ivacaftor 125 mg tablet, 112 (PI, CMI)	1	112	5	$17812.50	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11833TMP	TEZACAFTOR + IVACAFTOR (&) IVACAFTOR tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28], 56 (PI, CMI)	1	1	5	$19998.67	$31.60	$31.60
	Available brands
	Symdeko

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11834WMP	TEZACAFTOR + IVACAFTOR (&) IVACAFTOR tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28], 56 (PI, CMI)	1	1	5	$19998.67	$31.60	$31.60
	Available brands
	Symdeko

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11841FMP	LUMACAFTOR + IVACAFTOR lumacaftor 100 mg + ivacaftor 125 mg granules, 56 sachets (PI, CMI)	1	56	5	$17861.17	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11848NMP	LUMACAFTOR + IVACAFTOR lumacaftor 150 mg + ivacaftor 188 mg granules, 56 sachets (PI, CMI)	1	56	5	$17861.17	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11851RMP	LUMACAFTOR + IVACAFTOR lumacaftor 150 mg + ivacaftor 188 mg granules, 56 sachets (PI, CMI)	1	56	5	$17812.50	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11854XMP	TEZACAFTOR + IVACAFTOR (&) IVACAFTOR tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28], 56 (PI, CMI)	1	1	5	$19950.00	$31.60	$31.60
	Available brands
	Symdeko

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11863JMP	TEZACAFTOR + IVACAFTOR (&) IVACAFTOR tezacaftor 100 mg + ivacaftor 150 mg tablet [28] (&) ivacaftor 150 mg tablet [28], 56 (PI, CMI)	1	1	5	$19950.00	$31.60	$31.60
	Available brands
	Symdeko

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
11866MMP	LUMACAFTOR + IVACAFTOR lumacaftor 100 mg + ivacaftor 125 mg granules, 56 sachets (PI, CMI)	1	56	5	$17812.50	$31.60	$31.60
	Available brands
	Orkambi

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12936WMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 100 mg + tezacaftor 50 mg + ivacaftor 75 mg tablet [56] (&) ivacaftor 150 mg tablet [28], 84 (PI, CMI)	1	1	5	$21375.00	$31.60	$31.60
	Available brands
	Trikafta

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12938YMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 100 mg + tezacaftor 50 mg + ivacaftor 75 mg tablet [56] (&) ivacaftor 150 mg tablet [28], 84 (PI, CMI)	1	1	5	$21423.67	$31.60	$31.60
	Available brands
	Trikafta

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13266FMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 50 mg + tezacaftor 25 mg + ivacaftor 37.5 mg tablet [56] (&) ivacaftor 75 mg tablet [28], 84 (PI, CMI)	1	1	5	$21423.67	$31.60	$31.60
	Available brands
	Trikafta

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13276RMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 50 mg + tezacaftor 25 mg + ivacaftor 37.5 mg tablet [56] (&) ivacaftor 75 mg tablet [28], 84 (PI, CMI)	1	1	5	$21375.00	$31.60	$31.60
	Available brands
	Trikafta

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14147NMP	IVACAFTOR ivacaftor 25 mg granules, 56 sachets (PI, CMI)	1	56	5	$21423.67	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14148PMP	IVACAFTOR ivacaftor 50 mg granules, 56 sachets (PI, CMI)	1	56	5	$21375.00	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14153XMP	IVACAFTOR ivacaftor 150 mg tablet, 56 (PI, CMI)	1	56	5	$21375.00	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14155BMP	IVACAFTOR ivacaftor 25 mg granules, 56 sachets (PI, CMI)	1	56	5	$21375.00	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14156CMP	IVACAFTOR ivacaftor 25 mg granules, 56 sachets (PI, CMI)	1	56	5	$21375.00	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14157DMP	IVACAFTOR ivacaftor 75 mg granules, 56 sachets (PI, CMI)	1	56	5	$21423.67	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14158EMP	IVACAFTOR ivacaftor 50 mg granules, 56 sachets (PI, CMI)	1	56	5	$21423.67	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14165MMP	IVACAFTOR ivacaftor 25 mg granules, 56 sachets (PI, CMI)	1	56	5	$21423.67	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14167PMP	IVACAFTOR ivacaftor 75 mg granules, 56 sachets (PI, CMI)	1	56	5	$21375.00	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14169RMP	IVACAFTOR ivacaftor 150 mg tablet, 56 (PI, CMI)	1	56	5	$21423.67	$31.60	$31.60
	Available brands
	Kalydeco

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14227TMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 80 mg + tezacaftor 40 mg + ivacaftor 60 mg granules [28] (&) ivacaftor 59.5 mg granules [28], 56 (PI, CMI)	1	1	5	$21375.00	$31.60	$31.60
	Available brands
	Trikafta

Source	S100 HSD Public
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14228WMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 100 mg + tezacaftor 50 mg + ivacaftor 75 mg granules [28] (&) ivacaftor 75 mg granules [28], 56 (PI, CMI)	1	1	5	$21375.00	$31.60	$31.60
	Available brands
	Trikafta

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14279MMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 80 mg + tezacaftor 40 mg + ivacaftor 60 mg granules [28] (&) ivacaftor 59.5 mg granules [28], 56 (PI, CMI)	1	1	5	$21423.67	$31.60	$31.60
	Available brands
	Trikafta

Source	S100 HSD Private
Body System	RESPIRATORY SYSTEM > OTHER RESPIRATORY SYSTEM PRODUCTS > OTHER RESPIRATORY SYSTEM PRODUCTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14280NMP	ELEXACAFTOR + TEZACAFTOR + IVACAFTOR (&) IVACAFTOR elexacaftor 100 mg + tezacaftor 50 mg + ivacaftor 75 mg granules [28] (&) ivacaftor 75 mg granules [28], 56 (PI, CMI)	1	1	5	$21423.67	$31.60	$31.60
	Available brands
	Trikafta