SELEGILINE

SELEGILINE (14430L)

selegiline hydrochloride 5 mg tablet, 100
14430L
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Late stage Parkinson 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: 200 # of repeats: 5 DPMQ: $94.42 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Eldepryl

SELEGILINE (1973W)

selegiline hydrochloride 5 mg tablet, 100
1973W
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Late stage Parkinson 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: 100 # of repeats: 5 DPMQ: $54.10 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Eldepryl