GLYCOPYRRONIUM

GLYCOPYRRONIUM (10059K)

glycopyrronium 50 microgram powder for inhalation, 30 capsules
10059K
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Restricted Benefit

Restriction

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: 1 Max qty units: 30 # of repeats: 5 DPMQ: $59.70 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
seebri breezhaler

GLYCOPYRRONIUM (14417T)

glycopyrronium 50 microgram powder for inhalation, 30 capsules
14417T
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Restricted Benefit

Restriction

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: 60 # of repeats: 5 DPMQ: $105.62 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
seebri breezhaler

GLYCOPYRRONIUM (15337F)

Glycopyrronium 2.2 mg/actuation cream, 124 actuations
15337F
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18526)

Indication: Severe primary axillary hyperhidrosis
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: 2 DPMQ: $160.21 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Axhidrox