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
1509KMPNP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$16.05	$17.36	$20.65
	Available brands
	Poly-Tearsa
	Tears Naturalea * Additional charge for this brand is $3.85B	1	1	5	$19.90	$17.36	$24.50

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
5520MOP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$16.05	$17.36	$20.65
	Available brands
	Poly-Tearsa
	Tears Naturalea * Additional charge for this brand is $3.85B	1	1	5	$19.90	$17.36	$24.50

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
5521NOP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 28 x 0.4 mL unit doses (PI, CMI)	3	3	5	$37.04	$30.00	$30.00
	Available brands
	Bion Tears

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
8299TMPNP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 28 x 0.4 mL unit doses (PI, CMI)	3	3	5	$37.04	$30.00	$30.00
	Available brands
	Bion Tears

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

Note

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
9216CMP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL (PI, CMI)	1	1	11	$16.05	$17.36	$20.65
	Available brands
	Poly-Tearsa
	Tears Naturalea * Additional charge for this brand is $3.85B	1	1	11	$19.90	$17.36	$24.50