DOXYCYCLINE

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Severe acne

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 4	Max qty units: 28	# of repeats: 5	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $11.00			DPMQ: $36.32	Max safety net: $25.00	General Patient Charge: $36.00
Mayne Pharma Doxycycline *Additional charge for this brand is $5.72			DPMQ: $31.04	Max safety net: $25.00	General Patient Charge: $30.72

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Severe acne

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 8	Max qty units: 56	# of repeats: 2	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $22.00			DPMQ: $58.28	Max safety net: $25.00	General Patient Charge: $47.00
Mayne Pharma Doxycycline *Additional charge for this brand is $11.44			DPMQ: $47.72	Max safety net: $25.00	General Patient Charge: $36.44

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Pelvic inflammatory disease

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 4	Max qty units: 28	# of repeats: 0	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $11.00			DPMQ: $36.32	Max safety net: $25.00	General Patient Charge: $36.00
Mayne Pharma Doxycycline *Additional charge for this brand is $5.72			DPMQ: $31.04	Max safety net: $25.00	General Patient Charge: $30.72

Body System:

Manner of administration:Oral

General Schedule

No restrictions

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 7	# of repeats: 1	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $2.75			DPMQ: $19.85	Max safety net: $18.64	General Patient Charge: $24.18
Mayne Pharma Doxycycline *Additional charge for this brand is $1.43			DPMQ: $18.53	Max safety net: $18.64	General Patient Charge: $22.86

Body System:

Manner of administration:Oral

General Schedule

No restrictions

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 7	# of repeats: 0	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $2.75			DPMQ: $19.85	Max safety net: $18.64	General Patient Charge: $24.18
Mayne Pharma Doxycycline *Additional charge for this brand is $1.43			DPMQ: $18.53	Max safety net: $18.64	General Patient Charge: $22.86

DOXYCYCLINE (10777F)