TRIGLYCERIDES MEDIUM CHAIN FORMULA
triglycerides medium chain formula powder for oral liquid, 400 g
Body System:
Manner of administration:Oral
Restriction
Indication: Dietary management of conditions requiring a source of medium chain triglycerides
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $404.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Monogen | |||||
triglycerides medium chain formula powder for oral liquid, 400 g
Body System:
Manner of administration:Oral
Restriction
Indication: Dietary management of conditions requiring a source of medium chain triglycerides
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $265.60 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Peptamen Junior | |||||
triglycerides medium chain formula powder for oral liquid, 400 g
Body System:
Manner of administration:Oral
Restriction
Indication: Dietary management of conditions requiring a source of medium chain triglycerides
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $365.60 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Lipistart | |||||
triglycerides medium chain formula oral liquid, 12 x 500 mL bottles
Body System:
Manner of administration:Oral
Restriction
Indication: Dietary management of conditions requiring a source of medium chain triglycerides
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 12 | Max qty units: 12 | # of repeats: 5 | DPMQ: $1,553.40 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Nutrini Peptisorb | |||||
triglycerides medium chain formula powder for oral liquid, 400 g
Body System:
Manner of administration:Oral
Restriction
Indication: Hyperlipoproteinaemia type 1
Restriction
Indication: Long chain fatty acid oxidation disorders
Restriction
Indication: Chylous ascites
Restriction
Indication: Chylothorax
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $365.60 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Lipistart | |||||
triglycerides medium chain formula powder for oral liquid, 400 g
Body System:
Manner of administration:Oral
Restriction
Indication: Hyperlipoproteinaemia type 1
Restriction
Indication: Long chain fatty acid oxidation disorders
Restriction
Indication: Chylous ascites
Restriction
Indication: Chylothorax
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $404.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Monogen | |||||