LEVOTHYROXINE

LEVOTHYROXINE (12830G)

levothyroxine sodium 125 microgram tablet, 200
12830G
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $25.27 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Eltroxin

LEVOTHYROXINE (12960D)

levothyroxine sodium 75 microgram tablet, 2 x 100
12960D
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $22.57 Max safety net: $24.05 General Patient Charge: $25.00
Available brands
LEVOXINE
Thyrox

LEVOTHYROXINE (12968M)

levothyroxine sodium 100 microgram tablet, 2 x 100
12968M
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $22.74 Max safety net: $24.22 General Patient Charge: $25.00
Available brands
LEVOXINE
Thyrox

LEVOTHYROXINE (12969N)

levothyroxine sodium 50 microgram tablet, 2 x 100
12969N
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $22.42 Max safety net: $23.90 General Patient Charge: $25.00
Available brands
LEVOXINE
Thyrox

LEVOTHYROXINE (12970P)

levothyroxine sodium 200 microgram tablet, 2 x 100
12970P
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $24.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
LEVOXINE
Thyrox

LEVOTHYROXINE (2173J)

levothyroxine sodium 200 microgram tablet, 200
2173J
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $24.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $1.12
 DPMQ: $25.40 Max safety net: $25.00 General Patient Charge: $26.12

LEVOTHYROXINE (2174K)

levothyroxine sodium 50 microgram tablet, 200
2174K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $22.42 Max safety net: $23.90 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $1.12
 DPMQ: $23.54 Max safety net: $23.90 General Patient Charge: $26.12

LEVOTHYROXINE (2175L)

levothyroxine sodium 100 microgram tablet, 200
2175L
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $22.74 Max safety net: $24.22 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $1.11
 DPMQ: $23.85 Max safety net: $24.22 General Patient Charge: $26.11

LEVOTHYROXINE (9287T)

levothyroxine sodium 75 microgram tablet, 200
9287T
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $22.57 Max safety net: $24.05 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $1.13
 DPMQ: $23.70 Max safety net: $24.05 General Patient Charge: $26.13