AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT LYSINE AND LOW IN TRYPTOPHAN

AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT LYSINE AND LOW IN TRYPTOPHAN (10466W)

amino acid formula with vitamins and minerals without lysine and low in tryptophan powder for oral liquid, 500 g
10466W
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Proven glutaric aciduria type 1
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 9 Max qty units: 9 # of repeats: 5 DPMQ: $2,670.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
XLYS, LOW TRY Maxamum

AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT LYSINE AND LOW IN TRYPTOPHAN (10715Y)

amino acid formula with vitamins and minerals without lysine and low in tryptophan powder for oral liquid, 30 x 18 g sachets
10715Y
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Proven glutaric aciduria type 1
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 8 # of repeats: 5 DPMQ: $1,832.40 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
GA1 Anamix Junior

AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT LYSINE AND LOW IN TRYPTOPHAN (14781Y)

amino acid formula with vitamins and minerals without lysine and low in tryptophan containing 5 g of protein equivalent powder for oral liquid, 30 x 12.5 g sachets
14781Y
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Proven glutaric aciduria type 1

Restriction

Indication: Pyridoxine dependent epilepsy
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 8 # of repeats: 5 DPMQ: $1,832.40 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
GA explore5

AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT LYSINE AND LOW IN TRYPTOPHAN (2650L)

amino acid formula with vitamins and minerals without lysine and low in tryptophan powder for oral liquid, 400 g
2650L
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Proven glutaric aciduria type 1
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 8 # of repeats: 5 DPMQ: $667.36 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
GA1 Anamix infant