PRAMIPEXOLE

PRAMIPEXOLE (14556D)

pramipexole dihydrochloride monohydrate 2.25 mg modified release tablet, 30
14556D
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: $105.40 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (5143Q)

pramipexole dihydrochloride monohydrate 2.25 mg modified release tablet, 30
5143Q
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: $59.59 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER