METHADONE

METHADONE (13334T)

methadone hydrochloride 5 mg/mL oral liquid, 200 mL
13334T
Body System:
Manner of administration:Oral
S100 HSD Community Access
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16083)

Indication: Opioid dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4.2 Max qty units: 840 # of repeats: 5 DPMQ: $50.92 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Aspen Methadone Syrup
Biodone Forte

METHADONE (5399E)

methadone hydrochloride 5 mg/mL oral liquid, 200 mL
5399E
Body System:
Manner of administration:Oral
Palliative Care
Authority Required

Restriction

Indication: Chronic severe disabling pain
Treatment phase: Initial treatment, for up to 3 months
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 2 DPMQ: $27.79 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Aspen Methadone Syrup

METHADONE (5400F)

methadone hydrochloride 5 mg/mL oral liquid, 200 mL
5400F
Body System:
Manner of administration:Oral
Palliative Care
Authority Required

Restriction

Indication: Chronic severe disabling pain
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 0 DPMQ: $27.79 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Aspen Methadone Syrup