BACLOFEN
baclofen 10 mg/5 mL intrathecal injection, 10 x 5 mL ampoules
BACLOFEN (11126N)
11126N
Manner of administration:Injection
Restriction (Streamlined authority code: 6925)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 6939)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 6940)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 6911)
Indication: Severe chronic spasticity
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 10 | # of repeats: 0 | DPMQ: $762.70 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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