BUDESONIDE + FORMOTEROL

BUDESONIDE + FORMOTEROL (11273H)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
11273H
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7970)

Indication: Asthma
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: $37.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DuoResp Spiromax

BUDESONIDE + FORMOTEROL (12029D)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
12029D
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10464)

Indication: Mild asthma
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: 2 DPMQ: $37.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DuoResp Spiromax

BUDESONIDE + FORMOTEROL (12041R)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
12041R
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10464)

Indication: Mild asthma
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: 2 DPMQ: $37.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bufomix EASYHALER 200/6
Rilast TURBUHALER 200/6
Symbicort Turbuhaler 200/6
*Additional charge for this brand is $4.00
 DPMQ: $41.80 Max safety net: $25.00 General Patient Charge: $29.00

BUDESONIDE + FORMOTEROL (12093L)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
12093L
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10538)

Indication: Asthma
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: $37.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bufomix EASYHALER 200/6
DuoResp Spiromax
Rilast TURBUHALER 200/6
Symbicort Turbuhaler 200/6
*Additional charge for this brand is $4.00
 DPMQ: $41.80 Max safety net: $25.00 General Patient Charge: $29.00

BUDESONIDE + FORMOTEROL (14365C)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
14365C
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15577)

Indication: Asthma
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: $61.82 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bufomix EASYHALER 200/6
DuoResp Spiromax
Rilast TURBUHALER 200/6
Symbicort Turbuhaler 200/6
*Additional charge for this brand is $8.00
 DPMQ: $69.82 Max safety net: $25.00 General Patient Charge: $33.00

BUDESONIDE + FORMOTEROL (14434Q)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
14434Q
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15680)

Indication: Asthma
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: $61.82 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DuoResp Spiromax

BUDESONIDE + FORMOTEROL (14439Y)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
14439Y
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15680)

Indication: Asthma
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: $61.82 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bufomix EASYHALER 200/6
Rilast TURBUHALER 200/6
Symbicort Turbuhaler 200/6
*Additional charge for this brand is $8.00
 DPMQ: $69.82 Max safety net: $25.00 General Patient Charge: $33.00

BUDESONIDE + FORMOTEROL (8625Y)

budesonide 200 microgram/actuation + formoterol fumarate dihydrate 6 microgram/actuation powder for inhalation, 120 actuations
8625Y
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7970)

Indication: Asthma
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: $37.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bufomix EASYHALER 200/6
Rilast TURBUHALER 200/6
Symbicort Turbuhaler 200/6
*Additional charge for this brand is $4.00
 DPMQ: $41.80 Max safety net: $25.00 General Patient Charge: $29.00