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 (11842G)

hypromellose 0.3% w/v eye drops, 10 mL
11842G
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6172)

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: $25.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Evolve Hypromellose

HYPROMELLOSE (11849P)

hypromellose 0.3% w/v eye drops, 10 mL
11849P
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6172)

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: $25.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Evolve Hypromellose

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

HYPROMELLOSE (14320Q)

hypromellose 0.5% eye drops, 15 mL
14320Q
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: $21.32 Max safety net: $22.80 General Patient Charge: $25.00
Available brands
Methopt

HYPROMELLOSE (14492R)

hypromellose 0.3% w/v eye drops, 10 mL
14492R
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15559)

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: $36.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Evolve Hypromellose

HYPROMELLOSE (2956N)

hypromellose 0.5% eye drops, 15 mL
2956N
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: $17.55 Max safety net: $19.03 General Patient Charge: $21.82
Available brands
Methopt

HYPROMELLOSE (5517J)

hypromellose 0.5% eye drops, 15 mL
5517J
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: $17.55 Max safety net: $19.03 General Patient Charge: $21.82
Available brands
Methopt