DICLOXACILLIN

Body System:

Manner of administration:Oral

General Schedule

Authority Required (STREAMLINED)

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

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: $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

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: $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 (10790X)