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
9021TMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 125 mL pouches (PI, CMI)	4	4	5	$1,673.28	$25.00	$25.00
	Available brands
	PKU Lophlex LQ 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
9396MMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine oral liquid, 36 x 125 mL bottles (PI, CMI)	4	4	5	$1,042.08	$25.00	$25.00
	Available brands
	PKU Anamix Junior LQ

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
9397NMPNP	AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE amino acid formula with vitamins and minerals without phenylalanine oral liquid, 60 x 62.5 mL pouches (PI, CMI)	2	2	5	$681.02	$25.00	$25.00
	Available brands
	PKU Lophlex LQ 10