AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT METHIONINE
amino acid formula with vitamins and minerals without methionine oral liquid: powder
for, 30 x 36 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Pyridoxine non-responsive homocystinuria
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 | |||||
| HCU Anamix Junior | |||||
amino acid formula with vitamins and minerals without methionine powder for oral liquid,
30 x 29 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Pyridoxine non-responsive homocystinuria
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 | |||||
| HCU Lophlex | |||||
amino acid formula with vitamins and minerals without methionine oral liquid, 30 x
125 mL pouches
Body System:
Manner of administration:Oral
Restriction
Indication: Pyridoxine non-responsive homocystinuria
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 | |||||
| HCU Lophlex LQ 20 | |||||
amino acid formula with vitamins and minerals without methionine oral liquid, 30 x
174 mL sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Pyridoxine non-responsive homocystinuria
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 | |||||
| HCU cooler 20 | |||||
amino acid formula with vitamins and minerals without methionine powder for oral liquid,
400 g
Body System:
Manner of administration:Oral
Restriction
Indication: Pyridoxine non-responsive homocystinuria
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 | |||||
| HCU Anamix infant | |||||
amino acid formula with vitamins and minerals without methionine powder for oral liquid,
30 x 25 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Pyridoxine non-responsive homocystinuria
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 | |||||
| HCU express 15 | |||||