DICLOXACILLIN

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Serious staphylococcal infection

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 24	# of repeats: 0	DPMQ: $18.50	Max safety net: $19.98	General Patient Charge: $22.77
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 250
Distaph 250 *Additional charge for this brand is $1.86			DPMQ: $20.36	Max safety net: $19.98	General Patient Charge: $24.63

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Serious staphylococcal infection

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 24	# of repeats: 0	DPMQ: $18.50	Max safety net: $19.98	General Patient Charge: $22.77
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 250
Distaph 250 *Additional charge for this brand is $1.86			DPMQ: $20.36	Max safety net: $19.98	General Patient Charge: $24.63

DICLOXACILLIN (5096F)