BUDESONIDE + FORMOTEROL

BUDESONIDE + FORMOTEROL (10018G)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation inhalation, 120 actuations
10018G
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4404)

Indication: Asthma

Restriction (Streamlined authority code: 10121)

Indication: Chronic obstructive pulmonary disease (COPD)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 5 DPMQ: $61.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cipla Budesonide + Formoterol 200/6
Rilast RAPIHALER 200/6
Symbicort Rapihaler 200/6
*Additional charge for this brand is $4.96
 DPMQ: $66.20 Max safety net: $25.00 General Patient Charge: $29.96

BUDESONIDE + FORMOTEROL (12082X)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation inhalation, 120 actuations
12082X
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10538)

Indication: Asthma
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 5 DPMQ: $61.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cipla Budesonide + Formoterol 200/6
Rilast RAPIHALER 200/6
Symbicort Rapihaler 200/6
*Additional charge for this brand is $4.96
 DPMQ: $66.20 Max safety net: $25.00 General Patient Charge: $29.96

BUDESONIDE + FORMOTEROL (14436T)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation inhalation, 120 actuations
14436T
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15577)

Indication: Asthma
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $108.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cipla Budesonide + Formoterol 200/6
Rilast RAPIHALER 200/6
Symbicort Rapihaler 200/6
*Additional charge for this brand is $10.16
 DPMQ: $118.84 Max safety net: $25.00 General Patient Charge: $35.16

BUDESONIDE + FORMOTEROL (14468L)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation inhalation, 120 actuations
14468L
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15615)

Indication: Asthma

Restriction (Streamlined authority code: 15548)

Indication: Chronic obstructive pulmonary disease (COPD)
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $108.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cipla Budesonide + Formoterol 200/6
Rilast RAPIHALER 200/6
Symbicort Rapihaler 200/6
*Additional charge for this brand is $10.16
 DPMQ: $118.84 Max safety net: $25.00 General Patient Charge: $35.16