AMANTADINE

AMANTADINE (14486K)

amantadine hydrochloride 100 mg capsule, 100
14486K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
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: $56.00 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
AMANTAMED
Symmetrel 100

AMANTADINE (3016R)

amantadine hydrochloride 100 mg capsule, 100
3016R
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
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: $34.89 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
AMANTAMED
Symmetrel 100