CLONAZEPAM

CLONAZEPAM (11520H)

clonazepam 500 microgram tablet, 50
11520H
Body System:
Manner of administration:Oral
Palliative Care
Restricted Benefit

Restriction

Indication: For use in patients receiving palliative care
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 100 # of repeats: 3 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Rivotril
*Additional charge for this brand is $1.84
 DPMQ: $22.42 Max safety net: $22.06 General Patient Charge: $26.69

CLONAZEPAM (11559J)

clonazepam 500 microgram tablet, 50
11559J
Body System:
Manner of administration:Oral
General Schedule
Authority Required

Restriction

Indication: Epilepsy
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 200 # of repeats: 2 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Rivotril
*Additional charge for this brand is $3.68
 DPMQ: $31.04 Max safety net: $25.00 General Patient Charge: $28.68