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: $25.50 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: $22.88 Max safety net: $24.42 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: $23.04 Max safety net: $24.58 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: $22.74 Max safety net: $24.28 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: $24.54 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: $24.54 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 $1.08
 DPMQ: $25.62 Max safety net: $25.00 General Patient Charge: $26.08

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: $22.74 Max safety net: $24.28 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $1.08
 DPMQ: $23.82 Max safety net: $24.28 General Patient Charge: $26.08

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: $23.04 Max safety net: $24.58 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $1.08
 DPMQ: $24.12 Max safety net: $24.58 General Patient Charge: $26.08

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: $22.88 Max safety net: $24.42 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $1.10
 DPMQ: $23.98 Max safety net: $24.42 General Patient Charge: $26.10