MINOXIDIL

MINOXIDIL (14041B)

minoxidil 10 mg tablet, 100
14041B
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Severe refractory hypertension
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: $75.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Loniten

MINOXIDIL (2313R)

minoxidil 10 mg tablet, 100
2313R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Severe refractory hypertension
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: $44.71 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Loniten