GLYCOMACROPEPTIDE FORMULA WITH DOCOSAHEXAENOIC ACID AND LOW PHENYLALANINE
glycomacropeptide formula with docosahexaenoic acid and low phenylalanine powder for
oral liquid, 30 x 35 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
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: $1,984.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Sphere20 | |||||
GLYCOMACROPEPTIDE FORMULA WITH DOCOSAHEXAENOIC ACID AND LOW PHENYLALANINE (11245W)
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
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: $1,504.96 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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glycomacropeptide formula with docosahexaenoic acid and low phenylalanine oral liquid,
18 x 250 mL cartons
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 10 | Max qty units: 10 | # of repeats: 5 | DPMQ: $1,504.98 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU GMPro LQ | |||||
glycomacropeptide formula with docosahexaenoic acid and low phenylalanine oral liquid,
15 x 237 mL bottles
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
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: $1,984.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Sphere Liquid | |||||