BACLOFEN

BACLOFEN (11194E)

baclofen 40 mg/20 mL intrathecal injection, 20 mL ampoule
11194E
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9562)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 9525)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 9638)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 9606)

Indication: Severe chronic spasticity
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: 0 DPMQ: $644.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Sintetica Baclofen Intrathecal

BACLOFEN (11195F)

baclofen 40 mg/20 mL intrathecal injection, 20 mL ampoule
11195F
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7152)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 7134)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 7153)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 7148)

Indication: Severe chronic spasticity
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: 0 DPMQ: $611.38 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Sintetica Baclofen Intrathecal