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 (1003T)

aciclovir 200 mg tablet, 25
1003T
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5936)

Indication: Initial moderate to severe genital herpes
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 50 # of repeats: 0 DPMQ: $23.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Aciclovir Sandoz

ACICLOVIR (1007B)

aciclovir 200 mg tablet, 90
1007B
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5942)

Indication: Recurrent moderate to severe genital herpes
Treatment phase: Episodic treatment or suppressive therapy
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 90 # of repeats: 5 DPMQ: $31.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ACICLOVIR-WGR
APO-Aciclovir
ARX-ACICLOVIR
Aciclovir GH
Aciclovir Sandoz

ACICLOVIR (1052J)

aciclovir 800 mg tablet, 35
1052J
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5967)

Indication: Herpes zoster

Restriction (Streamlined authority code: 5959)

Indication: Herpes zoster ophthalmicus
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 35 # of repeats: 0 DPMQ: $35.81 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ACICLOVIR-WGR
APO-Aciclovir
ARX-ACICLOVIR
Aciclovir Sandoz

ACICLOVIR (1555W)

aciclovir 200 mg tablet, 50
1555W
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5936)

Indication: Initial moderate to severe genital herpes
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 0 DPMQ: $23.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Aciclovir
ARX-ACICLOVIR

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