BENZYDAMINE

BENZYDAMINE (1121B)

benzydamine hydrochloride 0.15% mouthwash, 500 mL
1121B
Body System:
Manner of administration:Oral Application
General Schedule
Restricted Benefit

Restriction

Indication: Mucositis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 1 DPMQ: $22.50 Max safety net: $23.98 General Patient Charge: $25.00
Available brands
Difflam

BENZYDAMINE (5032W)

benzydamine hydrochloride 0.15% mouthwash, 500 mL
5032W
Body System:
Manner of administration:Oral Application
General Schedule
Restricted Benefit

Restriction

Indication: Mucositis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $22.50 Max safety net: $23.98 General Patient Charge: $25.00
Available brands
Difflam

BENZYDAMINE (5385K)

benzydamine hydrochloride 0.15% mouthwash, 500 mL
5385K
Body System:
Manner of administration:Oral Application
Palliative Care
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6197)

Indication: Painful mouth
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 3 DPMQ: $22.50 Max safety net: $23.98 General Patient Charge: $25.00
Available brands
Difflam