GLYCOMACROPEPTIDE AND ESSENTIAL AMINO ACIDS WITH VITAMINS AND MINERALS
glycomacropeptide and essential amino acids with vitamins and minerals containing
15 g of protein equivalent oral liquid, 30 x 250 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $2,327.28 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Glytactin RTD 15 | |||||
glycomacropeptide and essential amino acids with vitamins and minerals containing
15 g of protein equivalent oral liquid, 30 x 250 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Tyrosinaemia
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $2,967.36 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Tylactin RTD | |||||
glycomacropeptide and essential amino acids with vitamins and minerals powder for
oral liquid, 60 x 20 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 5 | Max qty units: 5 | # of repeats: 5 | DPMQ: $1,318.18 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Restore | |||||
glycomacropeptide and essential amino acids with vitamins and minerals containing
20 g of protein equivalent powder for oral liquid, 30 x 32 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $3,048.80 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Build 20 | |||||
glycomacropeptide and essential amino acids with vitamins and minerals containing
15 g of protein equivalent bar, 14 x 81 g
Body System:
Manner of administration:Oral
Restriction
Indication: Tyrosinaemia
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $2,780.40 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Tylactin Complete | |||||
glycomacropeptide and essential amino acids with vitamins and minerals containing
15 g of protein equivalent oral liquid, 30 x 250 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $2,327.28 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Glytactin RTD 15 Lite | |||||
glycomacropeptide and essential amino acids with vitamins and minerals powder for
oral liquid, 30 x 40 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $2,327.36 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Camino Pro Bettermilk | |||||
glycomacropeptide and essential amino acids with vitamins and minerals containing
10 g of protein equivalent powder for oral liquid, 30 x 15 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $1,568.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Build 10 | |||||
glycomacropeptide and essential amino acids with vitamins and minerals bar, 7 x 81
g
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 14 | Max qty units: 14 | # of repeats: 5 | DPMQ: $1,909.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Camino Pro Complete | |||||