VANCOMYCIN

VANCOMYCIN (14696L)

vancomycin 500 mg injection, 1 vial
14696L
Body System:
Manner of administration:Injection
General Schedule
Restricted Benefit

Restriction

Indication: Infection
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 5 Max qty units: 5 # of repeats: 0 DPMQ: $35.33 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
VANCOMYCIN MEDSURGE
Vancomycin Juno
Vancomycin Viatris

VANCOMYCIN (3130R)

vancomycin 500 mg injection, 1 vial
3130R
Body System:
Manner of administration:Injection
General Schedule
Restricted Benefit

Restriction

Indication: Endocarditis
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: 0 DPMQ: $22.42 Max safety net: $23.90 General Patient Charge: $25.00
Available brands
VANCOMYCIN MEDSURGE
Vancomycin Juno
Vancomycin Viatris

VANCOMYCIN (3131T)

vancomycin 500 mg injection, 1 vial
3131T
Body System:
Manner of administration:Injection
General Schedule
Restricted Benefit

Restriction

Indication: Endophthalmitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 5 Max qty units: 5 # of repeats: 0 DPMQ: $35.33 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
VANCOMYCIN MEDSURGE
Vancomycin Juno
Vancomycin Viatris

VANCOMYCIN (3323X)

vancomycin 500 mg injection, 1 vial
3323X
Body System:
Manner of administration:Injection
General Schedule
Restricted Benefit

Restriction

Indication: Endocarditis
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: 0 DPMQ: $22.42 Max safety net: $23.90 General Patient Charge: $25.00
Available brands
VANCOMYCIN MEDSURGE
Vancomycin Juno
Vancomycin Viatris