Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
10993NMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
10997TMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
10998WMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
10999XMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
11000YMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
11004EMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
11016TMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
11023EMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox

Source	S100 Botulinum Toxin Program
Body System	MUSCULO-SKELETAL SYSTEM > MUSCLE RELAXANTS > MUSCLE RELAXANTS, PERIPHERALLY ACTING AGENTS

Caution

Note

Authority Required (STREAMLINED)

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
11751LMP	BOTULINUM TOXIN TYPE A botulinum toxin type A 100 units injection, 1 vial (PI, CMI)	4	4	0	$1098.88	$31.60	$31.60
	Available brands
	Botox