NORTRIPTYLINE

NORTRIPTYLINE (2522R)

nortriptyline 10 mg tablet, 50
2522R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Major depression

Restriction

Indication: Major depression
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 2 DPMQ: $18.65 Max safety net: $20.19 General Patient Charge: $22.98
Available brands
Allegron

NORTRIPTYLINE (2523T)

nortriptyline 25 mg tablet, 50
2523T
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Major depression

Restriction

Indication: Major depression
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 2 DPMQ: $20.06 Max safety net: $21.60 General Patient Charge: $24.39
Available brands
Allegron