Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

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
13100LMPNP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	2	2	5	$34.74	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

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
13113EOP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	2	2	5	$34.74	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

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
14421BMPNPOP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	2	2	5	$18.84	$20.32	$23.77
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

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
14520FMPNPOP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	4	4	5	$55.68	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

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
5524ROP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$16.31	$17.79	$21.24
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

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
8676PMPNP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$16.31	$17.79	$21.24
	Available brands
	Systane