HYPROMELLOSE

HYPROMELLOSE (11625W)

hypromellose 0.3% w/w eye drops, 10 mL
11625W
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
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: 5 DPMQ: $16.50 Max safety net: $17.98 General Patient Charge: $20.77
Available brands
Revive Tears

HYPROMELLOSE (11634H)

hypromellose 0.3% w/w eye drops, 10 mL
11634H
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
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: 5 DPMQ: $16.50 Max safety net: $17.98 General Patient Charge: $20.77
Available brands
Revive Tears

HYPROMELLOSE (14318N)

hypromellose 0.3% w/w eye drops, 10 mL
14318N
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
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: 5 DPMQ: $19.22 Max safety net: $20.70 General Patient Charge: $23.49
Available brands
Revive Tears