ACICLOVIR

ACICLOVIR (1002R)

aciclovir 3% eye ointment, 4.5 g
1002R
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Herpes simplex keratitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $28.93 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ViruPOS
XOROX

ACICLOVIR (5501M)

aciclovir 3% eye ointment, 4.5 g
5501M
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Herpes simplex keratitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $28.93 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ViruPOS
XOROX