ESOMEPRAZOLE
Manner of administration:Oral
Restriction (Streamlined authority code: 8776)
Indication: Gastro-oesophageal reflux disease
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
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| Max qty packs: 1 | Max qty units: 30 | # of repeats: 5 | DPMQ: $18.60 | Max safety net: $20.14 | General Patient Charge: $22.93 |
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DPMQ: $25.32 | Max safety net: $20.14 | General Patient Charge: $29.65 | ||
Manner of administration:Oral
Restriction
Indication: Complex gastro-oesophageal reflux disease (GORD)
Treatment phase: One of: (1) establishment of symptom control, (2) maintenance treatment, (3) re-establishment
of symptom control
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
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| Max qty packs: 2 | Max qty units: 60 | # of repeats: 5 | DPMQ: $22.84 | Max safety net: $24.38 | General Patient Charge: $25.00 |
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DPMQ: $36.28 | Max safety net: $24.38 | General Patient Charge: $38.44 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 15658)
Indication: Scleroderma oesophagus
Restriction (Streamlined authority code: 15682)
Indication: Pathological hypersecretory conditions including Zollinger-Ellison syndrome and idiopathic
hypersecretion
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 60 | # of repeats: 5 | DPMQ: $22.84 | Max safety net: $24.38 | General Patient Charge: $25.00 |
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DPMQ: $36.28 | Max safety net: $24.38 | General Patient Charge: $38.44 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 15530)
Indication: Gastro-oesophageal reflux disease
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 60 | # of repeats: 5 | DPMQ: $22.84 | Max safety net: $24.38 | General Patient Charge: $25.00 |
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DPMQ: $36.28 | Max safety net: $24.38 | General Patient Charge: $38.44 | ||
Manner of administration:Oral
Restriction
Indication: Complex gastro-oesophageal reflux disease (GORD)
Treatment phase: One of: (1) establishment of symptom control, (2) maintenance treatment, (3) re-establishment
of symptom control
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 120 | # of repeats: 5 | DPMQ: $31.32 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $58.20 | Max safety net: $25.00 | General Patient Charge: $51.88 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 8774)
Indication: Gastro-oesophageal reflux disease
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 30 | # of repeats: 1 | DPMQ: $18.60 | Max safety net: $20.14 | General Patient Charge: $22.93 |
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DPMQ: $25.32 | Max safety net: $20.14 | General Patient Charge: $29.65 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 8780)
Indication: Scleroderma oesophagus
Restriction (Streamlined authority code: 8827)
Indication: Pathological hypersecretory conditions including Zollinger-Ellison syndrome and idiopathic
hypersecretion
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 30 | # of repeats: 5 | DPMQ: $18.60 | Max safety net: $20.14 | General Patient Charge: $22.93 |
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DPMQ: $25.32 | Max safety net: $20.14 | General Patient Charge: $29.65 | ||
Manner of administration:Oral
Restriction (Streamlined authority code: 8775)
Indication: Peptic ulcer
Treatment phase: Initial treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 30 | # of repeats: 1 | DPMQ: $18.60 | Max safety net: $20.14 | General Patient Charge: $22.93 |
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DPMQ: $25.32 | Max safety net: $20.14 | General Patient Charge: $29.65 | ||