BUDESONIDE + FORMOTEROL

BUDESONIDE + FORMOTEROL (13258T)

budesonide 400 microgram/actuation + formoterol fumarate dihydrate 12 microgram/actuation powder for inhalation, 60 actuations
13258T
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7979)

Indication: Asthma

Restriction (Streamlined authority code: 10121)

Indication: Chronic obstructive pulmonary disease (COPD)
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: $61.26 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bufomix Easyhaler 400/12
DuoResp Spiromax
Rilast TURBUHALER 400/12
Symbicort TURBUHALER 400/12
*Additional charge for this brand is $4.00
 DPMQ: $65.26 Max safety net: $25.00 General Patient Charge: $29.00

BUDESONIDE + FORMOTEROL (14398T)

budesonide 400 microgram/actuation + formoterol fumarate dihydrate 12 microgram/actuation powder for inhalation, 60 actuations
14398T
Body System:
Manner of administration:Inhalation By Mouth
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15617)

Indication: Asthma

Restriction (Streamlined authority code: 15548)

Indication: Chronic obstructive pulmonary disease (COPD)
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: $108.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bufomix Easyhaler 400/12
DuoResp Spiromax
Rilast TURBUHALER 400/12
Symbicort TURBUHALER 400/12
*Additional charge for this brand is $8.12
 DPMQ: $116.84 Max safety net: $25.00 General Patient Charge: $33.12