HYALURONATE SODIUM

HYALURONATE SODIUM (14494W)

hyaluronate sodium 0.2% eye drops, 10 mL
14494W
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15559)

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: $56.50 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Hylo-Forte

HYALURONATE SODIUM (2171G)

hyaluronate sodium 0.2% eye drops, 10 mL
2171G
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6172)

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: $35.14 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Hylo-Forte

HYALURONATE SODIUM (2253N)

hyaluronate sodium 0.2% eye drops, 10 mL
2253N
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6172)

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: $35.14 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Hylo-Forte