DICLOXACILLIN

DICLOXACILLIN (10790X)

dicloxacillin 500 mg capsule, 24
10790X
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6188)

Indication: Osteomyelitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 48 # of repeats: 1 DPMQ: $30.00 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 500
Distaph 500
*Additional charge for this brand is $3.90
 DPMQ: $33.90 Max safety net: $25.00 General Patient Charge: $28.90

DICLOXACILLIN (5096F)

dicloxacillin 250 mg capsule, 24
5096F
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

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 (5097G)

dicloxacillin 500 mg capsule, 24
5097G
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

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: $21.89 Max safety net: $23.37 General Patient Charge: $25.00
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 500
Distaph 500
*Additional charge for this brand is $1.95
 DPMQ: $23.84 Max safety net: $23.37 General Patient Charge: $26.95

DICLOXACILLIN (8121K)

dicloxacillin 250 mg capsule, 24
8121K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

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 (8122L)

dicloxacillin 500 mg capsule, 24
8122L
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

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: $21.89 Max safety net: $23.37 General Patient Charge: $25.00
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 500
Distaph 500
*Additional charge for this brand is $1.95
 DPMQ: $23.84 Max safety net: $23.37 General Patient Charge: $26.95