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 $11.80			DPMQ: $36.36	Max safety net: $25.00	General Patient Charge: $36.80
Mayne Pharma Doxycycline *Additional charge for this brand is $6.16			DPMQ: $30.72	Max safety net: $25.00	General Patient Charge: $31.16

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 $23.60			DPMQ: $58.88	Max safety net: $25.00	General Patient Charge: $48.60
Mayne Pharma Doxycycline *Additional charge for this brand is $12.32			DPMQ: $47.60	Max safety net: $25.00	General Patient Charge: $37.32

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 $11.80			DPMQ: $36.36	Max safety net: $25.00	General Patient Charge: $36.80
Mayne Pharma Doxycycline *Additional charge for this brand is $6.16			DPMQ: $30.72	Max safety net: $25.00	General Patient Charge: $31.16

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 $2.95			DPMQ: $19.43	Max safety net: $17.96	General Patient Charge: $23.70
Mayne Pharma Doxycycline *Additional charge for this brand is $1.54			DPMQ: $18.02	Max safety net: $17.96	General Patient Charge: $22.29

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 $2.95			DPMQ: $19.43	Max safety net: $17.96	General Patient Charge: $23.70
Mayne Pharma Doxycycline *Additional charge for this brand is $1.54			DPMQ: $18.02	Max safety net: $17.96	General Patient Charge: $22.29

DOXYCYCLINE (10777F)