PRAMIPEXOLE

PRAMIPEXOLE (14325Y)

pramipexole dihydrochloride monohydrate 4.5 mg modified release tablet, 30
14325Y
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: 60 # of repeats: 5 DPMQ: $218.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (3422D)

pramipexole dihydrochloride monohydrate 4.5 mg modified release tablet, 30
3422D
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: 30 # of repeats: 5 DPMQ: $113.73 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER