BUDESONIDE + FORMOTEROL

BUDESONIDE + FORMOTEROL (10015D)

budesonide 100 microgram/actuation + formoterol fumarate dihydrate 3 microgram/actuation inhalation, 120 actuations
10015D
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4397)

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: $42.62 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rilast RAPIHALER 100/3
Symbicort Rapihaler 100/3
*Additional charge for this brand is $4.96
 DPMQ: $47.58 Max safety net: $25.00 General Patient Charge: $29.96

BUDESONIDE + FORMOTEROL (12042T)

budesonide 100 microgram/actuation + formoterol fumarate dihydrate 3 microgram/actuation inhalation, 120 actuations
12042T
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 10482)

Indication: Mild 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: 2 DPMQ: $42.62 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rilast RAPIHALER 100/3
Symbicort Rapihaler 100/3
*Additional charge for this brand is $4.96
 DPMQ: $47.58 Max safety net: $25.00 General Patient Charge: $29.96

BUDESONIDE + FORMOTEROL (12089G)

budesonide 100 microgram/actuation + formoterol fumarate dihydrate 3 microgram/actuation inhalation, 120 actuations
12089G
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: 2 Max qty units: 2 # of repeats: 5 DPMQ: $42.62 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rilast RAPIHALER 100/3
Symbicort Rapihaler 100/3
*Additional charge for this brand is $4.96
 DPMQ: $47.58 Max safety net: $25.00 General Patient Charge: $29.96

BUDESONIDE + FORMOTEROL (14467K)

budesonide 100 microgram/actuation + formoterol fumarate dihydrate 3 microgram/actuation inhalation, 120 actuations
14467K
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15702)

Indication: Asthma
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $71.44 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rilast RAPIHALER 100/3
Symbicort Rapihaler 100/3
*Additional charge for this brand is $9.92
 DPMQ: $81.36 Max safety net: $25.00 General Patient Charge: $34.92

BUDESONIDE + FORMOTEROL (14535B)

budesonide 100 microgram/actuation + formoterol fumarate dihydrate 3 microgram/actuation inhalation, 120 actuations
14535B
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: 4 Max qty units: 4 # of repeats: 5 DPMQ: $71.44 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rilast RAPIHALER 100/3
Symbicort Rapihaler 100/3
*Additional charge for this brand is $9.92
 DPMQ: $81.36 Max safety net: $25.00 General Patient Charge: $34.92