PROPYLENE GLYCOL

PROPYLENE GLYCOL (14768G)

propylene glycol 0.6% eye drops, 10 mL
14768G
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 5 DPMQ: $16.56 Max safety net: $18.04 General Patient Charge: $20.83
Available brands
Systane Balance

PROPYLENE GLYCOL (15242F)

propylene glycol 0.6% eye drops, 10 mL
15242F
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
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: $19.34 Max safety net: $20.82 General Patient Charge: $23.61
Available brands
Systane Balance