AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT VALINE, LEUCINE AND ISOLEUCINE
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
oral liquid: powder for, 30 x 36 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
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: $1,744.12 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD Anamix Junior | |||||
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
powder for oral liquid, 30 x 28 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
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: $3,359.96 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD Lophlex | |||||
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
oral liquid, 30 x 125 mL pouches
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 3 | Max qty units: 3 | # of repeats: 5 | DPMQ: $2,560.68 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD Lophlex LQ 20 | |||||
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
oral liquid, 30 x 130 mL pouches
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
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: $2,560.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD cooler 15 | |||||
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
powder for oral liquid, 400 g
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
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: $634.40 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD Anamix infant | |||||
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
oral liquid, 30 x 174 mL pouches
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
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: $3,359.96 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD cooler 20 | |||||
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
powder for oral liquid, 500 g
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
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: $2,241.04 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD Maxamum | |||||
amino acid formula with vitamins and minerals without valine, leucine and isoleucine
powder for oral liquid, 30 x 25 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Maple syrup urine disease
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: $2,560.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| MSUD express 15 | |||||