CLONAZEPAM

Body System:

Manner of administration:Oral

Palliative Care

Restricted Benefit

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 $1.72			DPMQ: $22.86	Max safety net: $22.68	General Patient Charge: $26.72

Body System:

Manner of administration:Oral

General Schedule

Authority Required

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 $3.44			DPMQ: $31.36	Max safety net: $25.00	General Patient Charge: $28.44

CLONAZEPAM (11520H)