DEXTRAN-70 + HYPROMELLOSE

DEXTRAN-70 + HYPROMELLOSE (14521G)

dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL
14521G
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: $21.32 Max safety net: $22.80 General Patient Charge: $25.00
Available brands
Poly-Tears
Tears Naturale
*Additional charge for this brand is $8.00
 DPMQ: $29.32 Max safety net: $22.80 General Patient Charge: $33.00

DEXTRAN-70 + HYPROMELLOSE (1509K)

dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL
1509K
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: $17.55 Max safety net: $19.03 General Patient Charge: $21.82
Available brands
Poly-Tears
Tears Naturale
*Additional charge for this brand is $4.00
 DPMQ: $21.55 Max safety net: $19.03 General Patient Charge: $25.82

DEXTRAN-70 + HYPROMELLOSE (5520M)

dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL
5520M
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: $17.55 Max safety net: $19.03 General Patient Charge: $21.82
Available brands
Poly-Tears
Tears Naturale
*Additional charge for this brand is $4.00
 DPMQ: $21.55 Max safety net: $19.03 General Patient Charge: $25.82