Source	Repatriation Pharmaceutical Benefits
Body System	VARIOUS > ALL OTHER NON-THERAPEUTIC PRODUCTS > ALL OTHER NON-THERAPEUTIC PRODUCTS

Note

Authority Required

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
4252TMP	DRESSING FOAM WITH SILVERR dressing foam with silver 7.5 cm x 7.5 cm dressing, 10 (PI, CMI)
	Available brands
	Allevyn Ag Adhesive 66800073	1	1	0	$183.03	$7.70	$7.70

Source	Repatriation Pharmaceutical Benefits
Body System	VARIOUS > ALL OTHER NON-THERAPEUTIC PRODUCTS > ALL OTHER NON-THERAPEUTIC PRODUCTS

Note

Authority Required

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
4255YMP	DRESSING FOAM WITH SILVERR dressing foam with silver 10 cm x 10 cm dressing, 10 (PI, CMI)
	Available brands
	Allevyn Ag Adhesive 66800075	1	1	0	$272.09	$7.70	$7.70

Source	Repatriation Pharmaceutical Benefits
Body System	VARIOUS > ALL OTHER NON-THERAPEUTIC PRODUCTS > ALL OTHER NON-THERAPEUTIC PRODUCTS

Note

Authority Required

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
4258DMP	DRESSING FOAM WITH SILVERR dressing foam with silver 12.5 cm x 12.5 cm dressing, 10 (PI, CMI)
	Available brands
	Allevyn Ag Adhesive 66800078	1	1	0	$337.92	$7.70	$7.70

Source	Repatriation Pharmaceutical Benefits
Body System	VARIOUS > ALL OTHER NON-THERAPEUTIC PRODUCTS > ALL OTHER NON-THERAPEUTIC PRODUCTS

Note

Authority Required

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
4259EMP	DRESSING FOAM WITH SILVERR dressing foam with silver 10 cm x 10 cm dressing, 10 (PI, CMI)
	Available brands
	Allevyn Ag Non-Adhesive 66800086	1	1	0	$277.31	$7.70	$7.70

Source	Repatriation Pharmaceutical Benefits
Body System	VARIOUS > ALL OTHER NON-THERAPEUTIC PRODUCTS > ALL OTHER NON-THERAPEUTIC PRODUCTS

Note

Authority Required

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
4263JMP	DRESSING FOAM WITH SILVERR dressing foam with silver 7.5 cm x 7.5 cm dressing, 10 (PI, CMI)
	Available brands
	Allevyn Ag Gentle Border 66800460	1	1	0	$183.03	$7.70	$7.70

Source	Repatriation Pharmaceutical Benefits
Body System	VARIOUS > ALL OTHER NON-THERAPEUTIC PRODUCTS > ALL OTHER NON-THERAPEUTIC PRODUCTS

Note

Authority Required

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
4266MMP	DRESSING FOAM WITH SILVERR dressing foam with silver 10 cm x 10 cm dressing, 10 (PI, CMI)
	Available brands
	Allevyn Ag Gentle Border 66800461	1	1	0	$272.09	$7.70	$7.70

Source	Repatriation Pharmaceutical Benefits
Body System	VARIOUS > ALL OTHER NON-THERAPEUTIC PRODUCTS > ALL OTHER NON-THERAPEUTIC PRODUCTS

Note

Authority Required

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
4270RMP	DRESSING FOAM WITH SILVERR dressing foam with silver 12.5 cm x 12.5 cm dressing, 10 (PI, CMI)
	Available brands
	Allevyn Ag Gentle Border 66800462	1	1	0	$337.92	$7.70	$7.70