CITRIC ACID + LAURYL SULFOACETATE SODIUM + SORBITOL

CITRIC ACID + LAURYL SULFOACETATE SODIUM + SORBITOL (14534Y)

sodium citrate dihydrate 450 mg/5 mL + lauryl sulfoacetate sodium 45 mg/5 mL + sorbitol 3.125 g/5 mL enema, 12 x 5 mL
14534Y
Body System:
Manner of administration:Rectal
General Schedule
Restricted Benefit

Restriction

Indication: Constipation

Restriction

Indication: Constipation

Restriction

Indication: Constipation

Restriction

Indication: Constipation

Restriction

Indication: Terminal malignant neoplasia

Restriction

Indication: Anorectal congenital abnormalities

Restriction

Indication: Megacolon
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: 2 DPMQ: $61.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Micolette

CITRIC ACID + LAURYL SULFOACETATE SODIUM + SORBITOL (2091C)

sodium citrate dihydrate 450 mg/5 mL + lauryl sulfoacetate sodium 45 mg/5 mL + sorbitol 3.125 g/5 mL enema, 12 x 5 mL
2091C
Body System:
Manner of administration:Rectal
General Schedule
Restricted Benefit

Restriction

Indication: Constipation

Restriction

Indication: Constipation

Restriction

Indication: Constipation

Restriction

Indication: Constipation

Restriction

Indication: Terminal malignant neoplasia

Restriction

Indication: Anorectal congenital abnormalities

Restriction

Indication: Megacolon
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: 2 DPMQ: $37.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Micolette

CITRIC ACID + LAURYL SULFOACETATE SODIUM + SORBITOL (4462W)

sodium citrate dihydrate 450 mg/5 mL + lauryl sulfoacetate sodium 45 mg/5 mL + sorbitol 3.125 g/5 mL enema, 4 x 5 mL
4462W
Body System:
Manner of administration:Rectal
Repatriation Pharmaceutical Benefits
No restrictions
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: 0 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Micolette DPMQ: $20.21 Max safety net: $7.70 General Patient Charge: $7.70

CITRIC ACID + LAURYL SULFOACETATE SODIUM + SORBITOL (5331N)

sodium citrate dihydrate 450 mg/5 mL + lauryl sulfoacetate sodium 45 mg/5 mL + sorbitol 3.125 g/5 mL enema, 12 x 5 mL
5331N
Body System:
Manner of administration:Rectal
Palliative Care
Restricted Benefit

Restriction

Indication: Constipation
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: 3 DPMQ: $37.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Micolette