HYPROMELLOSE

HYPROMELLOSE (14320Q)

hypromellose 0.5% eye drops, 15 mL
14320Q
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 5 DPMQ: $21.32 Max safety net: $22.80 General Patient Charge: $25.00
Available brands
Methopt

HYPROMELLOSE (2956N)

hypromellose 0.5% eye drops, 15 mL
2956N
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 5 DPMQ: $17.55 Max safety net: $19.03 General Patient Charge: $21.82
Available brands
Methopt

HYPROMELLOSE (5517J)

hypromellose 0.5% eye drops, 15 mL
5517J
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye syndrome
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 5 DPMQ: $17.55 Max safety net: $19.03 General Patient Charge: $21.82
Available brands
Methopt