CLOZAPINE

CLOZAPINE (10288L)

clozapine 200 mg tablet, 100
10288L
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4998)

Indication: Schizophrenia
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 0 DPMQ: $460.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Clopine 200
Clozitor

CLOZAPINE (10289M)

clozapine 25 mg tablet, 100
10289M
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4998)

Indication: Schizophrenia
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 0 DPMQ: $71.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Clopine 25
Clozaril 25
Clozitor

CLOZAPINE (10302F)

clozapine 50 mg tablet, 100
10302F
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4998)

Indication: Schizophrenia
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 0 DPMQ: $129.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Clopine 50
Clozitor

CLOZAPINE (10341G)

clozapine 50 mg/mL oral liquid, 100 mL
10341G
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4998)

Indication: Schizophrenia
Treatment phase: Continuing treatment
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: $155.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Clopine Suspension

CLOZAPINE (10358E)

clozapine 100 mg tablet, 100
10358E
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4998)

Indication: Schizophrenia
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 0 DPMQ: $234.94 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Clopine 100
Clozaril 100
Clozitor

CLOZAPINE (11415T)

clozapine 50 mg/mL oral liquid, 100 mL
11415T
Body System:
Manner of administration:Oral
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9490)

Indication: Schizophrenia
Treatment phase: Initial treatment
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: $149.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Versacloz

CLOZAPINE (11422E)

clozapine 50 mg/mL oral liquid, 100 mL
11422E
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4998)

Indication: Schizophrenia
Treatment phase: Continuing treatment
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: $155.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Versacloz

CLOZAPINE (11433R)

clozapine 50 mg/mL oral liquid, 100 mL
11433R
Body System:
Manner of administration:Oral
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5015)

Indication: Schizophrenia
Treatment phase: Initial treatment
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: $135.00 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Versacloz

CLOZAPINE (5626D)

clozapine 50 mg tablet, 100
5626D
Body System:
Manner of administration:Oral
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5015)

Indication: Schizophrenia
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 0 DPMQ: $110.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Clopine 50
Clozitor

CLOZAPINE (5627E)

clozapine 200 mg tablet, 100
5627E
Body System:
Manner of administration:Oral
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5015)

Indication: Schizophrenia
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 0 DPMQ: $416.16 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Clopine 200
Clozitor