Source	General Schedule
Body System	VARIOUS > GENERAL NUTRIENTS > OTHER NUTRIENTS

Restricted Benefit

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
10411YMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 174 mL pouches (PI, CMI)	4	4	5	$1692.60	$31.60	$31.60
	Available brands
	PKU Air 20

Source	General Schedule
Body System	VARIOUS > GENERAL NUTRIENTS > OTHER NUTRIENTS

Restricted Benefit

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
1909LMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine powder for oral liquid, 30 x 34 g sachets (PI, CMI)	4	4	5	$1692.60	$31.60	$31.60
	Available brands
	PKU express 20

Source	General Schedule
Body System	VARIOUS > GENERAL NUTRIENTS > OTHER NUTRIENTS

Restricted Benefit

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
2382JMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 87 mL pouches (PI, CMI)	4	4	5	$849.96	$31.60	$31.60
	Available brands
	PKU Cooler 10

Source	General Schedule
Body System	VARIOUS > GENERAL NUTRIENTS > OTHER NUTRIENTS

Restricted Benefit

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
2474FMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 174 mL pouches (PI, CMI)	4	4	5	$1692.60	$31.60	$31.60
	Available brands
	PKU Cooler 20

Source	General Schedule
Body System	VARIOUS > GENERAL NUTRIENTS > OTHER NUTRIENTS

Restricted Benefit

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
5483NMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 85 g sachets (PI, CMI)	4	4	5	$868.88	$31.60	$31.60
	Available brands
	PKU squeezie